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General NPI Number Information
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NPI Number | 1962051219
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Entity Type | Individual
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Provider Name | WILLIAM RAYMOND BRADLEY
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Gender | Male
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Dates
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Enumeration Date | 09/10/2019
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Last Update Date | 10/26/2023
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Provider Practice Location Address
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Address Line | 332 BIRNIE AVE
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City | SPRINGFIELD
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State | MA
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Zip | 01107-1104
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Country | US
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Telephone | 413-733-6624
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Fax |
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Provider Business Mailing Address
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Address Line | 72 PROSPECT ST
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City | STAFFORD SPRINGS
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State | CT
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Zip | 06076-1125
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Country | US
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Telephone | 860-458-8008
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 6525
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License Number State | CT
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Legacy Identifiers
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Identifier #1
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Identifier Code | 6525
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Identifier Type | OTHER
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Identifier State | CT
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Identifier Issuer | LPC LICENSURE
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Proprietary Identifiers Ever Reported
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Identifier #1
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Identifier Code | 6525
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Identifier Type | OTHER
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Identifier State | CT
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Identifier Issuer | LPC LICENSURE
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