Provider Demographics
NPI:1750356515
Name:BRADLEY, MICHAEL (EDD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 DELANEY RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-6062
Mailing Address - Country:US
Mailing Address - Phone:910-762-9083
Mailing Address - Fax:910-763-6339
Practice Address - Street 1:2450 DELANEY RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6062
Practice Address - Country:US
Practice Address - Phone:910-762-9083
Practice Address - Fax:910-763-6339
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC977103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC071992OtherVALU OPTIONS
NC6000593Medicaid
NC03457OtherBC/BS
NC126105OtherCOMPSYCH
NC2491345Medicare ID - Type Unspecified