Provider Demographics
NPI:1871275685
Name:BRADLEY, LAURA LOUISE
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LOUISE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 E COTTAGE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02125-2601
Mailing Address - Country:US
Mailing Address - Phone:502-338-4698
Mailing Address - Fax:
Practice Address - Street 1:247 WASHINGTON AVE APT 9
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-1313
Practice Address - Country:US
Practice Address - Phone:857-816-9078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76656235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist