Provider Demographics
NPI:1841423456
Name:BRADLEY, GREGORY MAURICE JR (LMBT, MMP)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:MAURICE
Last Name:BRADLEY
Suffix:JR
Gender:M
Credentials:LMBT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7541 PILOT COVE CT
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-9450
Mailing Address - Country:US
Mailing Address - Phone:704-578-7365
Mailing Address - Fax:
Practice Address - Street 1:16501 NORTHCROSS DR STE D
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-5040
Practice Address - Country:US
Practice Address - Phone:980-222-4787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-29
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20138225700000X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171W00000XOther Service ProvidersContractor