Provider Demographics
NPI:1396589792
Name:BRADLEY, MAYA VICTORIA (MED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:VICTORIA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 OLD MAST CV
Mailing Address - Street 2:
Mailing Address - City:LIZELLA
Mailing Address - State:GA
Mailing Address - Zip Code:31052-3648
Mailing Address - Country:US
Mailing Address - Phone:478-361-8625
Mailing Address - Fax:
Practice Address - Street 1:905 ARROWHEAD TRL
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-5390
Practice Address - Country:US
Practice Address - Phone:478-333-6076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-20
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP012995235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist