Provider Demographics
NPI:1639565278
Name:BRADLEY, SHANIQUA J (LCSW)
Entity type:Individual
Prefix:
First Name:SHANIQUA
Middle Name:J
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1042 GROVE ST FL 2
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-2440
Mailing Address - Country:US
Mailing Address - Phone:908-943-6443
Mailing Address - Fax:
Practice Address - Street 1:1042 GROVE ST FL 2
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-2440
Practice Address - Country:US
Practice Address - Phone:908-943-6443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055711001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical