Provider Demographics
NPI:1386700334
Name:BRAGDON, CAROLE S (MSW, LCSW)
Entity type:Individual
Prefix:
First Name:CAROLE
Middle Name:S
Last Name:BRAGDON
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6838 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1029
Mailing Address - Country:US
Mailing Address - Phone:315-449-3925
Mailing Address - Fax:
Practice Address - Street 1:6838 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1029
Practice Address - Country:US
Practice Address - Phone:315-449-3925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0401581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY55709BMedicare ID - Type Unspecified