Provider Demographics
NPI:1740760669
Name:BRADLEY, DOTHERIA ELAINE (BA)
Entity Type:Individual
Prefix:MRS
First Name:DOTHERIA
Middle Name:ELAINE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1918 45TH ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-3042
Mailing Address - Country:US
Mailing Address - Phone:727-485-5235
Mailing Address - Fax:
Practice Address - Street 1:1918 45TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-3042
Practice Address - Country:US
Practice Address - Phone:727-485-5235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid