Provider Demographics
NPI:1215113758
Name:LONG, BRADLY ALAN
Entity type:Individual
Prefix:
First Name:BRADLY
Middle Name:ALAN
Last Name:LONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-2105
Mailing Address - Country:US
Mailing Address - Phone:323-481-5878
Mailing Address - Fax:
Practice Address - Street 1:3219 PIERCE ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-5910
Practice Address - Country:US
Practice Address - Phone:510-559-3013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80990106H00000X
CA91279106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist