Basic Information
| Provider Information | |||||||||
| NPI: | 1598350795 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | DEJRAH | ||||||||
| MiddleName: | MONIQUE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1581 | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740131581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184028723 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6333 E SKELLY DR | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741356106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186644224 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2021 | ||||||||
| LastUpdateDate: | 03/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | N | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103TP2701X | N | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy | 103TA0400X | Y | Behavioral Health & Social Service Providers | Psychologist | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1588706048 | 05 | OK | MEDICAID |