Provider Demographics
NPI:1972125516
Name:BRADLEY, ALLYANA CELEST
Entity type:Individual
Prefix:
First Name:ALLYANA
Middle Name:CELEST
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2632 REPUBLIC ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70119-1321
Mailing Address - Country:US
Mailing Address - Phone:303-944-2575
Mailing Address - Fax:
Practice Address - Street 1:733 DANTE ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70118-1013
Practice Address - Country:US
Practice Address - Phone:504-517-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-16
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO151770725106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician