Provider Demographics
NPI:1184312894
Name:BRADBURY, MARK L (MA, LMFTA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:L
Last Name:BRADBURY
Suffix:
Gender:M
Credentials:MA, LMFTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 WALNUT ACRES RD
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-9788
Mailing Address - Country:US
Mailing Address - Phone:208-740-4382
Mailing Address - Fax:
Practice Address - Street 1:416 WALNUT ACRES RD
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-9788
Practice Address - Country:US
Practice Address - Phone:208-740-4382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2024-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMG61552309106H00000X
WA61552309101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2243555Medicaid