Provider Demographics
NPI:1366595381
Name:BRADLEY, ERIN (CCC,SLP)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:CCC,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 SOLANA DR
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-3653
Mailing Address - Country:US
Mailing Address - Phone:650-592-7570
Mailing Address - Fax:650-591-3114
Practice Address - Street 1:1405 SOLANA DR
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-3653
Practice Address - Country:US
Practice Address - Phone:650-592-7570
Practice Address - Fax:650-591-3114
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004640235Z00000X
CA17166235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582606738OtherTAX ID
GA000947053AMedicaid