Provider Demographics
NPI:1720254246
Name:BRADLEY, DOUGLAS (CASAC)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 COVERT ST APT 3R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-1071
Mailing Address - Country:US
Mailing Address - Phone:718-737-5675
Mailing Address - Fax:
Practice Address - Street 1:26 COVERT ST APT 3R
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-1071
Practice Address - Country:US
Practice Address - Phone:718-737-5675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12104101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)