Provider Demographics
NPI:1154310720
Name:BRADLEY, LISA A (ACSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 W LUDINGTON AVE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:LUDINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:49431-2377
Mailing Address - Country:US
Mailing Address - Phone:231-843-8877
Mailing Address - Fax:231-845-0264
Practice Address - Street 1:409 W LUDINGTON AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-2377
Practice Address - Country:US
Practice Address - Phone:231-843-8877
Practice Address - Fax:231-845-0264
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILB0646301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N98050Medicare ID - Type Unspecified