Provider Demographics
NPI:1386714079
Name:BRADLEY, ROBERT RAY JR (LCSW, LSATP, CSAC,)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:RAY
Last Name:BRADLEY
Suffix:JR
Gender:M
Credentials:LCSW, LSATP, CSAC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 247
Mailing Address - Street 2:
Mailing Address - City:ACHILLES
Mailing Address - State:VA
Mailing Address - Zip Code:23001-0247
Mailing Address - Country:US
Mailing Address - Phone:757-812-1358
Mailing Address - Fax:
Practice Address - Street 1:751 THIMBLE SHOALS BLVD
Practice Address - Street 2:SUITE K
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-3563
Practice Address - Country:US
Practice Address - Phone:757-812-1358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040036921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010103550Medicaid