Provider Demographics
NPI:1407254204
Name:BRADLEY, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 PLYMOUTH RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-1638
Mailing Address - Country:US
Mailing Address - Phone:610-941-3390
Mailing Address - Fax:
Practice Address - Street 1:4610 E STREET RD
Practice Address - Street 2:
Practice Address - City:TREVOSE
Practice Address - State:PA
Practice Address - Zip Code:19053-6612
Practice Address - Country:US
Practice Address - Phone:610-941-3390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007745101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional