Provider Demographics
NPI:1306113642
Name:BRADLEY, TERESA R (LCSW, LCAC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:R
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LCSW, LCAC
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:R
Other - Last Name:SANDIFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, LCAC
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8401 HARCOURT RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2036
Practice Address - Country:US
Practice Address - Phone:317-338-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-30
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001383A101YA0400X
IN34006341A101YA0400X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300004581Medicaid