Provider Demographics
NPI:1609363126
Name:TAYLOR, BRADLEY R SR
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:R
Last Name:TAYLOR
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2697 INTERNATIONAL PKWY STE 104-1
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7805
Mailing Address - Country:US
Mailing Address - Phone:757-486-1143
Mailing Address - Fax:757-486-1663
Practice Address - Street 1:4360 SHORE DR STE 101
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-2994
Practice Address - Country:US
Practice Address - Phone:757-251-0879
Practice Address - Fax:984-220-9437
Is Sole Proprietor?:No
Enumeration Date:2018-04-19
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000469101YA0400X
VA0710102138101YA0400X
VA0701007601101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)