Provider Demographics
NPI:1760924716
Name:BRADLEY, SHANTI (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:SHANTI
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 DONMOYER AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-1863
Mailing Address - Country:US
Mailing Address - Phone:574-310-4014
Mailing Address - Fax:
Practice Address - Street 1:701 N NILES AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1923
Practice Address - Country:US
Practice Address - Phone:574-393-9955
Practice Address - Fax:574-393-9955
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst