Healthcare Provider Details

I. General information

NPI: 1982064002
Provider Name (Legal Business Name): BRADLEY HOLLEY LLPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 N M 52 STE 1
OWOSSO MI
48867-1025
US

IV. Provider business mailing address

863 N PINE RD STE A
ESSEXVILLE MI
48732-2159
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-8239
  • Fax: 989-391-9596
Mailing address:
  • Phone: 989-928-3566
  • Fax: 989-391-9596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401015306
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6401017764
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: