Provider Demographics
NPI:1821764499
Name:BRADLEY, CORY LEA
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:LEA
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 1:1901 N LAKES PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5939
Mailing Address - Country:US
Mailing Address - Phone:208-890-7165
Mailing Address - Fax:208-739-4425
Practice Address - Street 1:992 W IDAHO AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2111
Practice Address - Country:US
Practice Address - Phone:208-405-0020
Practice Address - Fax:208-739-4425
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-430721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical