Healthcare Provider Details

I. General information

NPI: 1659656528
Provider Name (Legal Business Name): TROY D BRADLEY MSW,LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. TROY DONAVON BRADLEY II

II. Dates (important events)

Enumeration Date: 10/11/2011
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 CANYON CREST DR STE 103
RIVERSIDE CA
92507-6353
US

IV. Provider business mailing address

5225 CANYON CREST DR STE 103
RIVERSIDE CA
92507-6353
US

V. Phone/Fax

Practice location:
  • Phone: 951-248-4000
  • Fax:
Mailing address:
  • Phone: 951-248-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number75059
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: