Provider Demographics
NPI:1770779464
Name:BRADLEY, LORETTA JEAN (PHD)
Entity type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:JEAN
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9312 RALEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-5110
Mailing Address - Country:US
Mailing Address - Phone:806-438-1233
Mailing Address - Fax:
Practice Address - Street 1:4404 IDALOU RD
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79403-9554
Practice Address - Country:US
Practice Address - Phone:806-762-0481
Practice Address - Fax:806-767-0571
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX11184101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional