Provider Demographics
NPI:1770234684
Name:BRADLEY, RAVEN (DC)
Entity Type:Individual
Prefix:DR
First Name:RAVEN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 NORTH LOOP W STE 120
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018-8126
Mailing Address - Country:US
Mailing Address - Phone:346-291-6790
Mailing Address - Fax:
Practice Address - Street 1:2030 NORTH LOOP W STE 120
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018-8126
Practice Address - Country:US
Practice Address - Phone:346-291-6790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14159111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85-1527654OtherNON-MEDICARE