Healthcare Provider Details

I. General information

NPI: 1619401650
Provider Name (Legal Business Name): SHERRY ANN BRADLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 05/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3270 KERNER BLVD
SAN RAFAEL CA
94901-4840
US

IV. Provider business mailing address

29 MARY ST
SAN RAFAEL CA
94901-3507
US

V. Phone/Fax

Practice location:
  • Phone: 415-473-6004
  • Fax:
Mailing address:
  • Phone: 415-526-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: