Healthcare Provider Details

I. General information

NPI: 1780508697
Provider Name (Legal Business Name): MR. SHALAKO MONGOSANTA BRADLEY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8795 PRESTON TRACE BLVD STE 300
FRISCO TX
75033-3788
US

IV. Provider business mailing address

2405 PALMER CIR STE 100
NORMAN OK
73069-6351
US

V. Phone/Fax

Practice location:
  • Phone: 855-782-7822
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: