Healthcare Provider Details

I. General information

NPI: 1184832883
Provider Name (Legal Business Name): BRADLEY ALLEN WEST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

WATTERS CENTER FOR FAMILY LIFE 1-3358 KNOX STREET
FORT BRAGG NC
28310-5000
US

IV. Provider business mailing address

885 FREDONIA DR
FAYETTEVILLE NC
28311-9333
US

V. Phone/Fax

Practice location:
  • Phone: 910-396-6564
  • Fax:
Mailing address:
  • Phone: 910-485-3765
  • Fax: 910-396-3826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: