Provider Demographics
NPI:1700187036
Name:BRADLEY, RYAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W. GRAND AVE.
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046
Mailing Address - Country:US
Mailing Address - Phone:847-356-3322
Mailing Address - Fax:
Practice Address - Street 1:5465 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-4913
Practice Address - Country:US
Practice Address - Phone:847-356-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-008896103TC0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker