Healthcare Provider Details

I. General information

NPI: 1083631634
Provider Name (Legal Business Name): TRICIA LYNN BRADLEY RD, LDN, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 03/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9120 W 95TH ST UNIT 3A
HICKORY HILLS IL
60457-1686
US

IV. Provider business mailing address

9120 W 95TH ST UNIT 3A
HICKORY HILLS IL
60457-1686
US

V. Phone/Fax

Practice location:
  • Phone: 708-598-5913
  • Fax:
Mailing address:
  • Phone: 708-598-5913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: