Provider Demographics
NPI:1720606106
Name:BRADLEY, VERDA R (PHD, LCSW, MED,)
Entity Type:Individual
Prefix:
First Name:VERDA
Middle Name:R
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PHD, LCSW, MED,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 S HOLT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-1119
Mailing Address - Country:US
Mailing Address - Phone:310-649-1002
Mailing Address - Fax:
Practice Address - Street 1:1061 E HYDE PARK BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-1801
Practice Address - Country:US
Practice Address - Phone:213-434-8183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-11
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS103361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty