Provider Demographics
NPI:1881360378
Name:BRADLEY, ROYCE BLAIR
Entity type:Individual
Prefix:
First Name:ROYCE
Middle Name:BLAIR
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 1:1443 15TH ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-4021
Mailing Address - Country:US
Mailing Address - Phone:304-444-0889
Mailing Address - Fax:
Practice Address - Street 1:120 HANWORTH LN
Practice Address - Street 2:
Practice Address - City:DANIELS
Practice Address - State:WV
Practice Address - Zip Code:25832-9029
Practice Address - Country:US
Practice Address - Phone:304-542-3544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist