Provider Demographics
NPI:1093822876
Name:BRADLEY, HEATHER LEE (PHD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LEE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 N PIEDMONT WAY
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-7974
Mailing Address - Country:US
Mailing Address - Phone:850-692-6326
Mailing Address - Fax:850-692-6976
Practice Address - Street 1:1408 N PIEDMONT WAY
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-7974
Practice Address - Country:US
Practice Address - Phone:850-692-6326
Practice Address - Fax:850-692-6976
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6826103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73127OtherBLUE CROSS PROVIDER NUMBE
FL591917016OtherCOMMERCIAL INSURANCE
FL591917016OtherCOMMERCIAL INSURANCE