Provider Demographics
NPI:1386113389
Name:HART, BRADLEY LAURENCE
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:LAURENCE
Last Name:HART
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 1:929 ACEQUIA MADRE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-2885
Mailing Address - Country:US
Mailing Address - Phone:218-259-2582
Mailing Address - Fax:
Practice Address - Street 1:929 ACEQUIA MADRE
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-2885
Practice Address - Country:US
Practice Address - Phone:218-259-2582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst