1184276511 NPI number — BRADLEY ADAIR VATTILANA MS, LMHC

Table of content: BRADLEY ADAIR VATTILANA MS, LMHC (NPI 1184276511)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184276511 NPI number — BRADLEY ADAIR VATTILANA MS, LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VATTILANA
Provider First Name:
BRADLEY
Provider Middle Name:
ADAIR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, LMHC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184276511
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22904 LYDEN DR UNIT 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ESTERO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33928-7048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-494-3951
Provider Business Mailing Address Fax Number:
239-217-9561

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22904 LYDEN DR UNIT 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESTERO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33928-7048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-494-3951
Provider Business Practice Location Address Fax Number:
239-217-9561
Provider Enumeration Date:
07/16/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MH21446 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 112904400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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