=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447510060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANN MARIE BRADLEY ENTERPRISES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2012
-----------------------------------------------------
Last Update Date | 05/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 N MAIN ST
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48170-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-416-3341
-----------------------------------------------------
Fax | 734-416-3345
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 N MAIN ST
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48170-1236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-416-3341
-----------------------------------------------------
Fax | 734-416-3345
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING CEO
-----------------------------------------------------
Name | SHELLEY TAGLIONE
-----------------------------------------------------
Credential | BILLING CEO
-----------------------------------------------------
Telephone | 734-414-0754
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | AB059736
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------