Provider Demographics
NPI:1336667328
Name:BRADLEY, NOLAN
Entity Type:Individual
Prefix:
First Name:NOLAN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1629 W REGAL ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-3455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6707 EMBARCADERO DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-3382
Practice Address - Country:US
Practice Address - Phone:209-956-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker