Provider Demographics
NPI:1912521154
Name:BRADLEY-BULLOCK, THEREASA MARIE (MPA)
Entity Type:Individual
Prefix:
First Name:THEREASA
Middle Name:MARIE
Last Name:BRADLEY-BULLOCK
Suffix:
Gender:F
Credentials:MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1766
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-5366
Mailing Address - Country:US
Mailing Address - Phone:252-578-6744
Mailing Address - Fax:877-352-0133
Practice Address - Street 1:1119 OAKLAND ST
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-3441
Practice Address - Country:US
Practice Address - Phone:252-578-6744
Practice Address - Fax:877-352-0133
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician