Provider Demographics
NPI:1215401302
Name:KECK, BRADLEY (CDCA, CPRS)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:KECK
Suffix:
Gender:M
Credentials:CDCA, CPRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 ELMWOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-5402
Mailing Address - Country:US
Mailing Address - Phone:937-384-0580
Mailing Address - Fax:937-384-0581
Practice Address - Street 1:100 ELMWOOD PARK DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45449-5402
Practice Address - Country:US
Practice Address - Phone:937-384-0580
Practice Address - Fax:937-384-0581
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175T00000X
OHCDCA.188574101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist