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NPI Code Detail

MEDICARE: ELISE VANDERLIST BRADLEY MSW

MEDICARE: ELISE VANDERLIST BRADLEY MSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker127315CA

General Provider Information

NPI Number : 1043876246
Entity Type Code : Individual
Provider Name (Legal Business Name) : ELISE VANDERLIST BRADLEY MSW
Provider Business Mailing Address
First Line : 3671 BUSINESS DR
Second Line :
City : SACRAMENTO
State : CA
Zip : 95820-2197
Country : US
Telephone Number : 916-215-0237
Fax Number :
Provider Business Practice Location Address
First Line : 3671 BUSINESS DR
Second Line :
City : SACRAMENTO
State : CA
Zip : 95820-2197
Country : US
Telephone Number : 916-215-0237
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/13/2019
Last Update Date : 03/05/2026

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