Provider Demographics
NPI:1639644511
Name:BRADLEY, RANDI DAWN (BS, LCMT, CRM, MMP)
Entity Type:Individual
Prefix:MS
First Name:RANDI
Middle Name:DAWN
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:BS, LCMT, CRM, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 RENNIE CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3946
Mailing Address - Country:US
Mailing Address - Phone:757-621-9615
Mailing Address - Fax:
Practice Address - Street 1:1213 LASKIN RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-5260
Practice Address - Country:US
Practice Address - Phone:757-621-9615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019011982225700000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist