Provider Demographics
NPI:1801133491
Name:BRADLEY, DEIRDRE VANESSA (LMT)
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:VANESSA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 MAYLYN AVE
Mailing Address - Street 2:
Mailing Address - City:DALLASTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17313-9208
Mailing Address - Country:US
Mailing Address - Phone:443-756-4472
Mailing Address - Fax:
Practice Address - Street 1:140 MAYLYN AVE
Practice Address - Street 2:
Practice Address - City:DALLASTOWN
Practice Address - State:PA
Practice Address - Zip Code:17313-9208
Practice Address - Country:US
Practice Address - Phone:443-756-4472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG002269174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist