Provider Demographics
NPI:1366510307
Name:BONNELLBRADLEY, SHARON LEE (LICSW)
Entity type:Individual
Prefix:MS
First Name:SHARON
Middle Name:LEE
Last Name:BONNELLBRADLEY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:84 HIGH ST
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3844
Mailing Address - Country:US
Mailing Address - Phone:781-391-1640
Mailing Address - Fax:781-391-1640
Practice Address - Street 1:84 HIGH ST
Practice Address - Street 2:SUITE 2B
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3844
Practice Address - Country:US
Practice Address - Phone:781-391-1640
Practice Address - Fax:781-391-1640
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1024763101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA550010005757OtherPACIFICARE PROVIDER ID
MA986151OtherNETWORK PROVIDER ID
MA003450OtherMBHP PROVIDER ID
MA1013390OtherBEACON HEALTH STRATEGIES
MA7925159OtherAETNA PROVIDER ID
MAP07505OtherBCBSPROVIDER ID
MA003450OtherVALUE OPTIONS PROVIDER ID
MA314436OtherMBC PROVIDER ID
MA793613OtherTUFTS PROVIDER ID
MA1851489Medicaid
MAP07505OtherBCBSPROVIDER ID