Provider Demographics
NPI:1992242440
Name:BRADLEY, GEORGE (LPC)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 NE STALLINGS DRIVE
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965
Mailing Address - Country:US
Mailing Address - Phone:936-645-8084
Mailing Address - Fax:
Practice Address - Street 1:3524 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-8728
Practice Address - Country:US
Practice Address - Phone:936-560-6855
Practice Address - Fax:936-564-5232
Is Sole Proprietor?:No
Enumeration Date:2017-01-23
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15898101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional