Healthcare Provider Details

I. General information

NPI: 1184276511
Provider Name (Legal Business Name): BRADLEY ADAIR VATTILANA MS, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22904 LYDEN DR UNIT 104
ESTERO FL
33928-7048
US

IV. Provider business mailing address

22904 LYDEN DR UNIT 104
ESTERO FL
33928-7048
US

V. Phone/Fax

Practice location:
  • Phone: 239-494-3951
  • Fax: 239-217-9561
Mailing address:
  • Phone: 239-494-3951
  • Fax: 239-217-9561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH21446
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: