Provider Demographics
NPI:1821439969
Name:BRADLEY, MARY KATHERINE (MS/CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 EVERETT AVE
Mailing Address - Street 2:APT 3
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-2228
Mailing Address - Country:US
Mailing Address - Phone:270-839-5025
Mailing Address - Fax:
Practice Address - Street 1:1427 EVERETT AVE
Practice Address - Street 2:APT 3
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-2228
Practice Address - Country:US
Practice Address - Phone:270-839-5025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-16
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3691235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist