Provider Demographics
NPI:1811186604
Name:BRADLEY, LATRECE
Entity Type:Individual
Prefix:MS
First Name:LATRECE
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10428 LOWER AZUSA RD.
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-3523
Mailing Address - Country:US
Mailing Address - Phone:626-228-0013
Mailing Address - Fax:
Practice Address - Street 1:10428 LOWER AZUSA RD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-1208
Practice Address - Country:US
Practice Address - Phone:626-228-0013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2016-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171M00000XOtherMHW-CM