Provider Demographics
NPI:1437274776
Name:BRADLEY, STACY DENISE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:DENISE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5261 CARROLLTON PIKE
Mailing Address - Street 2:SUITE E
Mailing Address - City:WOODLAWN
Mailing Address - State:VA
Mailing Address - Zip Code:24381
Mailing Address - Country:US
Mailing Address - Phone:276-601-6197
Mailing Address - Fax:
Practice Address - Street 1:620 TOM HUNTER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-5511
Practice Address - Country:US
Practice Address - Phone:276-601-6197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2023-09-01
Deactivation Date:2012-05-03
Deactivation Code:
Reactivation Date:2020-05-15
Provider Licenses
StateLicense IDTaxonomies
NC2845103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical