Healthcare Provider Details

I. General information

NPI: 1982915526
Provider Name (Legal Business Name): NICOLE GENEVIEVE BRADLEY MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 LOS ALAMOS AVE SW
ALBUQUERQUE NM
87104-1121
US

IV. Provider business mailing address

1625 LOS ALAMOS AVE SW
ALBUQUERQUE NM
87104-1121
US

V. Phone/Fax

Practice location:
  • Phone: 505-261-8453
  • Fax:
Mailing address:
  • Phone: 505-261-8453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0014529
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: