Basic Information
| Provider Information | |||||||||
| NPI: | 1972680478 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | LCMHC, MLADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 WALL ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031011518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036684111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 CYPRESS ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 031033628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036684111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 03/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0260 | NH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 109 | NH | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 020258994-13 | 01 | NH | HARVARD PILGRIM | OTHER | 1039161 | 01 | NH | CIGNA | OTHER | 3003541Y0NH01 | 01 | NH | BLUE CROSS | OTHER |