Provider Demographics
NPI:1215162045
Name:BRADLEY, NANCY (MFT,)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MFT,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4202
Mailing Address - Country:US
Mailing Address - Phone:707-799-7647
Mailing Address - Fax:707-634-6136
Practice Address - Street 1:633 CHERRY ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4202
Practice Address - Country:US
Practice Address - Phone:707-799-7647
Practice Address - Fax:707-634-6136
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-22
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 47990106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist