Provider Demographics
NPI:1184276511
Name:VATTILANA, BRADLEY ADAIR (MS, LMHC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ADAIR
Last Name:VATTILANA
Suffix:
Gender:M
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22904 LYDEN DR UNIT 104
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-7048
Mailing Address - Country:US
Mailing Address - Phone:239-494-3951
Mailing Address - Fax:239-217-9561
Practice Address - Street 1:22904 LYDEN DR UNIT 104
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-7048
Practice Address - Country:US
Practice Address - Phone:239-494-3951
Practice Address - Fax:239-217-9561
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21446101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health