Provider Demographics
NPI:1578963187
Name:BRADLEY, KELLY E (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:E
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6640 INTECH BLVD STE 195
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-2014
Practice Address - Country:US
Practice Address - Phone:317-295-0608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IN20043645A103TC0700X, 103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical