Provider Demographics
NPI:1962150664
Name:BRADLEY, MISTY TASHINA (LMT)
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:TASHINA
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-6104 KIPEHI PL
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-7959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75-127 LUNAPULE RD STE 4B
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2119
Practice Address - Country:US
Practice Address - Phone:808-345-3863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-13
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPRE-LICENCED101YP2500X
HIMAT-15794225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional