MEDICARE: BRADLEY W & LISA C HOLDER

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1497609291
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRADLEY W & LISA C HOLDER

Provider Business Mailing Address
First Line	:	3310 DELOR AVE
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34286-7102
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3310 DELOR AVE
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34286-7102
Country	:	US
Telephone Number	:	719-492-1317
Fax Number	:

Authorized Official
Title or Position	:	ONWER
Name	:	LISA C HOLDER
Credential	:
Telephone Number	:	719-492-1317

Provider Enumeration Date	:	02/26/2026
Last Update Date	:	02/26/2026

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