Provider Demographics
NPI:1497200521
Name:BRADLEY, MALLORY BOEHLER (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:BOEHLER
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 ROSEDALE RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-6106
Mailing Address - Country:US
Mailing Address - Phone:731-439-0642
Mailing Address - Fax:
Practice Address - Street 1:719 ROSEDALE RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-6106
Practice Address - Country:US
Practice Address - Phone:731-439-0642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009174235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist