Healthcare Provider Details

I. General information

NPI: 1700274677
Provider Name (Legal Business Name): RAQUEL BRADLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2014
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14586 W PORT AU PRINCE LN
SURPRISE AZ
85379-8551
US

IV. Provider business mailing address

14586 W PORT AU PRINCE LN
SURPRISE AZ
85379-8551
US

V. Phone/Fax

Practice location:
  • Phone: 623-238-4187
  • Fax:
Mailing address:
  • Phone: 623-238-4187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4475510
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: