Provider Demographics
NPI:1417614447
Name:BRADLEY, OCTAVIA (BA)
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 MILLBURN AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3714
Mailing Address - Country:US
Mailing Address - Phone:973-850-9554
Mailing Address - Fax:
Practice Address - Street 1:2115 MILLBURN AVE STE 104
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3714
Practice Address - Country:US
Practice Address - Phone:973-850-9554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-24
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ83-2600221OtherTAX IDENTIFICATION NUMBER
NJ832600221OtherTAX IDENTIFICATION