Healthcare Provider Details

I. General information

NPI: 1497609291
Provider Name (Legal Business Name): BRADLEY W & LISA C HOLDER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2026
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3310 DELOR AVE
NORTH PORT FL
34286-7102
US

IV. Provider business mailing address

3310 DELOR AVE
NORTH PORT FL
34286-7102
US

V. Phone/Fax

Practice location:
  • Phone: 719-492-1317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: LISA C HOLDER
Title or Position: ONWER
Credential:
Phone: 719-492-1317