Provider Demographics
NPI:1568934420
Name:BRADLEY, MARY (CG60735677)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:CG60735677
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2422 96TH ST S APT J105
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-1782
Mailing Address - Country:US
Mailing Address - Phone:805-217-5654
Mailing Address - Fax:
Practice Address - Street 1:2422 96TH ST S APT J105
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-1782
Practice Address - Country:US
Practice Address - Phone:805-217-5654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60735677101YM0800X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACG60735677Medicaid