Provider Demographics
NPI:1851644348
Name:JACQUELINE BRADLEY-DIVER
Entity Type:Organization
Organization Name:JACQUELINE BRADLEY-DIVER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR SPECIALIST - MT
Authorized Official - Prefix:MS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BRADLEY-DIVER
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:610-357-1817
Mailing Address - Street 1:416 TROLLEY WAY
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-4310
Mailing Address - Country:US
Mailing Address - Phone:610-357-1817
Mailing Address - Fax:
Practice Address - Street 1:416 TROLLEY WAY
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19382-4310
Practice Address - Country:US
Practice Address - Phone:610-357-1817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-21
Last Update Date:2012-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health