Provider Demographics
NPI:1952853442
Name:BRADLEY, LISA MARIE (MA, R-DMT, LPCI)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MA, R-DMT, LPCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61843 DOBBIN RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9536
Mailing Address - Country:US
Mailing Address - Phone:458-206-0337
Mailing Address - Fax:
Practice Address - Street 1:60575 BILLADEAU RD
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-9338
Practice Address - Country:US
Practice Address - Phone:541-382-9410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-31
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC5758101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health