Healthcare Provider Details

I. General information

NPI: 1962051219
Provider Name (Legal Business Name): WILLIAM RAYMOND BRADLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2019
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 BIRNIE AVE
SPRINGFIELD MA
01107-1104
US

IV. Provider business mailing address

72 PROSPECT ST
STAFFORD SPRINGS CT
06076-1125
US

V. Phone/Fax

Practice location:
  • Phone: 413-733-6624
  • Fax:
Mailing address:
  • Phone: 860-458-8008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6525
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6525
Identifier TypeOTHER
Identifier StateCT
Identifier IssuerLPC LICENSURE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: