MEDICARE: BRADLEY ERIC MACK

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
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1497522551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY ERIC MACK

Provider Business Mailing Address
First Line	:	1501 W COLONIAL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-7120
Country	:	US
Telephone Number	:	321-271-4346
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 W COLONIAL DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-7120
Country	:	US
Telephone Number	:	407-440-1861
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/08/2023
Last Update Date	:	12/08/2023

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Directions to “ BRADLEY ERIC MACK ” Practice Location

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