Provider Demographics
NPI:1457470981
Name:BRADLEY, SHAUNDA L (OC)
Entity Type:Individual
Prefix:
First Name:SHAUNDA
Middle Name:L
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:OC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 RUCKEL DR STE 300
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1722
Mailing Address - Country:US
Mailing Address - Phone:850-598-4045
Mailing Address - Fax:850-598-4045
Practice Address - Street 1:314 RUCKEL DR
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1722
Practice Address - Country:US
Practice Address - Phone:850-598-4045
Practice Address - Fax:850-598-4045
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1400698225X00000X
FL22872225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist