Healthcare Provider Details

I. General information

NPI: 1497094098
Provider Name (Legal Business Name): BRADLEY MCCALLISTER M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S BETHLEHEM PIKE
AMBLER PA
19002-5818
US

IV. Provider business mailing address

355 ELM AVE
GLENSIDE PA
19038-3011
US

V. Phone/Fax

Practice location:
  • Phone: 215-643-7676
  • Fax: 215-542-9219
Mailing address:
  • Phone: 304-412-4514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: