Provider Demographics
NPI:1972363208
Name:BRADLEY, MEKEISHA (CEO, CMA)
Entity type:Individual
Prefix:MS
First Name:MEKEISHA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:CEO, CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 SIX FORKS RD STE 102
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6427
Mailing Address - Country:US
Mailing Address - Phone:919-900-7145
Mailing Address - Fax:919-741-5865
Practice Address - Street 1:6900 SIX FORKS RD STE 102
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6427
Practice Address - Country:US
Practice Address - Phone:919-926-9255
Practice Address - Fax:919-741-5865
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 363A00000X
NC27601101YA0400X
NC1660101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant