Provider Demographics
NPI:1962051219
Name:BRADLEY, WILLIAM RAYMOND
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RAYMOND
Last Name:BRADLEY
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 1:72 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076-1125
Mailing Address - Country:US
Mailing Address - Phone:860-458-8008
Mailing Address - Fax:
Practice Address - Street 1:332 BIRNIE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1104
Practice Address - Country:US
Practice Address - Phone:413-733-6624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6525101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT6525OtherLPC LICENSURE