Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 106S00000X | Behavior Technician | 17-28108 | SC |
NPI | 1003310459 |
---|---|
Provider Name | Charlene Bradley |
First Address | Bowling Green, KY 42104-3250 |
Second Address | Sumter, SC 29150-1749 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2018 |
Last Update Date | 21/03/2018 |