Provider Demographics
NPI:1568974384
Name:CORRY, BRADLEY (BCABA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:CORRY
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S 700 E STE 2A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2855
Mailing Address - Country:US
Mailing Address - Phone:801-935-4171
Mailing Address - Fax:801-906-0410
Practice Address - Street 1:515 S 700 E STE 2A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2855
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:801-935-4171
Is Sole Proprietor?:No
Enumeration Date:2017-11-02
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
UT11477183-2507106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician