Provider Demographics
NPI:1194295022
Name:BRADLEY, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 WINN WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1707
Mailing Address - Country:US
Mailing Address - Phone:404-243-9500
Mailing Address - Fax:
Practice Address - Street 1:3310 CLIFTON SPRINGS RD STE B
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034
Practice Address - Country:US
Practice Address - Phone:404-243-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-04
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400942860709376K00000X
171M00000X
GAMSW010289101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No376K00000XNursing Service Related ProvidersNurse's Aide
No171M00000XOther Service ProvidersCase Manager/Care Coordinator