Provider Demographics
NPI:1457648693
Name:BRADLEY, MARK EDWARD (CLINICIAN)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:CLINICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 FAIRMOUNT ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-7613
Mailing Address - Country:US
Mailing Address - Phone:978-342-2709
Mailing Address - Fax:
Practice Address - Street 1:63 FAIRMOUNT ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-7613
Practice Address - Country:US
Practice Address - Phone:978-342-2709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health