Provider Demographics
NPI:1467188789
Name:BRADLEY, VAKISHA
Entity Type:Individual
Prefix:
First Name:VAKISHA
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 1:8022 TIMBERLAKE RD APT 27
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-2662
Mailing Address - Country:US
Mailing Address - Phone:434-363-7466
Mailing Address - Fax:
Practice Address - Street 1:1332 PLANTATION RD NE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-5713
Practice Address - Country:US
Practice Address - Phone:540-725-1572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA22-204493106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician