Provider Demographics
NPI:1376690776
Name:BRADLEY, KATHLEEN LOUISE (P T)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:LOUISE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 671
Mailing Address - Street 2:
Mailing Address - City:COBB
Mailing Address - State:CA
Mailing Address - Zip Code:95426-0671
Mailing Address - Country:US
Mailing Address - Phone:707-928-6712
Mailing Address - Fax:
Practice Address - Street 1:991 PARALLEL DR
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453
Practice Address - Country:US
Practice Address - Phone:707-263-4338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 30664167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician