Provider Demographics
NPI:1033466503
Name:BRADLEY, EDWARD G JR (LPC)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:G
Last Name:BRADLEY
Suffix:JR
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 1:223 N 3RD ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-6609
Mailing Address - Country:US
Mailing Address - Phone:918-682-7797
Mailing Address - Fax:918-686-8881
Practice Address - Street 1:223 N 3RD ST
Practice Address - Street 2:SUITE 104
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-6609
Practice Address - Country:US
Practice Address - Phone:918-682-7797
Practice Address - Fax:918-686-8881
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK478101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health