Provider Demographics
NPI:1598376196
Name:BRADLEY, MICHAELA NICOLE (MA)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:NICOLE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10021 STRATMORE CIR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71115-3416
Mailing Address - Country:US
Mailing Address - Phone:240-467-6685
Mailing Address - Fax:
Practice Address - Street 1:10021 STRATMORE CIR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-3416
Practice Address - Country:US
Practice Address - Phone:240-467-6685
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator