Provider Demographics
NPI:1164284550
Name:BRADLEY, DERRICK (LPCC-S, LCADC)
Entity Type:Individual
Prefix:MR
First Name:DERRICK
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LPCC-S, LCADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 HIGHWAY 26 STE C
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-9047
Mailing Address - Country:US
Mailing Address - Phone:606-219-8130
Mailing Address - Fax:
Practice Address - Street 1:3265 HIGHWAY 26
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-9047
Practice Address - Country:US
Practice Address - Phone:606-555-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY167193101YA0400X
KY104136101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)