Provider Demographics
NPI:1831650688
Name:BRADLEY, DEANNA MICHELE
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:MICHELE
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 1:272 COUNTY FARM RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-6003
Mailing Address - Country:US
Mailing Address - Phone:603-516-8160
Mailing Address - Fax:
Practice Address - Street 1:272 COUNTY FARM RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-6003
Practice Address - Country:US
Practice Address - Phone:603-516-8173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1072101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3097970Medicaid