Provider Demographics
NPI:1174175640
Name:MIX, BRADLEE JAYDE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:BRADLEE
Middle Name:JAYDE
Last Name:MIX
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HICKORY TER
Mailing Address - Street 2:
Mailing Address - City:WELLSBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16901-1300
Mailing Address - Country:US
Mailing Address - Phone:570-337-4487
Mailing Address - Fax:
Practice Address - Street 1:300 SCHUYLKILL MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3668
Practice Address - Country:US
Practice Address - Phone:570-621-9500
Practice Address - Fax:570-621-9510
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPSL000361235Z00000X
PASL014647235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist