Provider Demographics
NPI:1013259977
Name:BRADLEY, LAWRENCE WILLIAM (BHRS)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:WILLIAM
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8716 RAMBLING RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73132-3119
Mailing Address - Country:US
Mailing Address - Phone:405-720-2835
Mailing Address - Fax:
Practice Address - Street 1:8716 RAMBLING RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73132-3119
Practice Address - Country:US
Practice Address - Phone:405-720-2835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKASCX12Medicaid