Provider Demographics
NPI:1720315187
Name:BRADLEY, AMY J (LISW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:CLOUSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW
Mailing Address - Street 1:401 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-1736
Mailing Address - Country:US
Mailing Address - Phone:419-584-5123
Mailing Address - Fax:
Practice Address - Street 1:401 E MARKET ST
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-1736
Practice Address - Country:US
Practice Address - Phone:419-584-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.13023591041C0700X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical