Provider Demographics
NPI:1528449170
Name:MARINE, BRADLEY DALE (LPCC)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:DALE
Last Name:MARINE
Suffix:
Gender:M
Credentials:LPCC
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Mailing Address - Street 1:12701 TOWNEPARK WAY
Mailing Address - Street 2:BARKLEY BLDG. STE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2384
Mailing Address - Country:US
Mailing Address - Phone:502-254-8880
Mailing Address - Fax:502-254-8870
Practice Address - Street 1:12701 TOWNEPARK WAY
Practice Address - Street 2:BARKLEY BLDG. STE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-2384
Practice Address - Country:US
Practice Address - Phone:502-254-8880
Practice Address - Fax:502-254-8870
Is Sole Proprietor?:No
Enumeration Date:2015-06-09
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KYLPCPCC00218860101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional