Provider Demographics
NPI:1639731664
Name:BRADLEY-BLUE, STEPHANIE (PC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BRADLEY-BLUE
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 N BIRDNECK RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-6368
Mailing Address - Country:US
Mailing Address - Phone:757-422-0684
Mailing Address - Fax:757-422-0841
Practice Address - Street 1:615 N BIRDNECK RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6368
Practice Address - Country:US
Practice Address - Phone:757-422-0684
Practice Address - Fax:757-422-0841
Is Sole Proprietor?:No
Enumeration Date:2019-06-29
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional