Provider Demographics
NPI:1457894388
Name:BRADLEY, JUANITA
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 NE MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-2086
Mailing Address - Country:US
Mailing Address - Phone:503-676-7371
Mailing Address - Fax:503-430-5403
Practice Address - Street 1:3311 NE MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2086
Practice Address - Country:US
Practice Address - Phone:503-676-7371
Practice Address - Fax:503-430-5403
Is Sole Proprietor?:No
Enumeration Date:2016-11-26
Last Update Date:2016-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-CRM-121175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist