Basic Information
| Provider Information | |||||||||
| NPI: | 1750356515 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ED.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2450 DELANEY RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107629083 | ||||||||
| FaxNumber: | 9107636339 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 DELANEY RD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107629083 | ||||||||
| FaxNumber: | 9107636339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2006 | ||||||||
| LastUpdateDate: | 09/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 977 | NC | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 071992 | 01 | NC | VALU OPTIONS | OTHER | 6000593 | 05 | NC | MEDICAID | 03457 | 01 | NC | BC/BS | OTHER | 126105 | 01 | NC | COMPSYCH | OTHER |