Provider Demographics
NPI:1669228037
Name:BRADLEY, STACIE
Entity type:Individual
Prefix:
First Name:STACIE
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 1:7741 ROSWELL RD
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30350-4845
Mailing Address - Country:US
Mailing Address - Phone:678-524-2102
Mailing Address - Fax:
Practice Address - Street 1:7741 ROSWELL RD
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30350-4845
Practice Address - Country:US
Practice Address - Phone:678-524-2102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health