Provider Demographics
NPI:1891042206
Name:LANDON, BRADLEY L
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:L
Last Name:LANDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 VILLAGE HILL RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01096-9706
Mailing Address - Country:US
Mailing Address - Phone:407-782-6162
Mailing Address - Fax:
Practice Address - Street 1:111 COUNTY CIR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:MA
Practice Address - Zip Code:01003-9255
Practice Address - Country:US
Practice Address - Phone:407-782-6162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-06
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2255141041C0700X
MA1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical