Provider Demographics
NPI:1558722538
Name:BRADLEY, PORSHA
Entity Type:Individual
Prefix:
First Name:PORSHA
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 1:1970 ST. LANDRY HWY
Mailing Address - Street 2:
Mailing Address - City:ST. LANDRY
Mailing Address - State:LA
Mailing Address - Zip Code:71367-3034
Mailing Address - Country:US
Mailing Address - Phone:504-236-8783
Mailing Address - Fax:318-253-2222
Practice Address - Street 1:1970 ST. LANDRY HWY
Practice Address - Street 2:
Practice Address - City:ST. LANDRY
Practice Address - State:LA
Practice Address - Zip Code:71367-3034
Practice Address - Country:US
Practice Address - Phone:504-236-8783
Practice Address - Fax:318-253-2222
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LANONEOtherNONE