Basic Information
| Provider Information | |||||||||
| NPI: | 1407254204 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | DIANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 521 PLYMOUTH RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194621638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109413390 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4610 E STREET RD | ||||||||
| Address2: | |||||||||
| City: | TREVOSE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190536612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109413390 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2014 | ||||||||
| LastUpdateDate: | 12/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | PC007745 | PA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.