Provider Demographics
NPI:1336494707
Name:BRADLEY, COLLEEN (MSED)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 SERPENTINE LN
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-3804
Mailing Address - Country:US
Mailing Address - Phone:516-506-8060
Mailing Address - Fax:516-465-9834
Practice Address - Street 1:8 SERPENTINE LN
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-3804
Practice Address - Country:US
Practice Address - Phone:516-506-8060
Practice Address - Fax:516-465-9834
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2012-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY776443101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY14379270OtherNEW YORK STATE DEPARTMENT OF HEALTH