Provider Demographics
NPI:1831102631
Name:BRADBURY, RANDY (LICSW)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:BRADBURY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:WESTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01027-9512
Mailing Address - Country:US
Mailing Address - Phone:413-529-1764
Mailing Address - Fax:
Practice Address - Street 1:39 UNION ST
Practice Address - Street 2:
Practice Address - City:EASTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01027-1468
Practice Address - Country:US
Practice Address - Phone:413-529-1764
Practice Address - Fax:413-529-9047
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1102191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP30134Medicare ID - Type Unspecified