Provider Demographics
NPI:1184192981
Name:BRADLEY, KEVIN (LCSW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12408 ALEXANDER CORNELL DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2414
Mailing Address - Country:US
Mailing Address - Phone:703-658-9054
Mailing Address - Fax:
Practice Address - Street 1:12408 ALEXANDER CORNELL DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2414
Practice Address - Country:US
Practice Address - Phone:703-658-9054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040107651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical