Provider Demographics
NPI:1225422686
Name:BRADLEY KORNEGAY, LCSW, LCAS, PLLC
Entity Type:Organization
Organization Name:BRADLEY KORNEGAY, LCSW, LCAS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KORNEGAY
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW, LCAS
Authorized Official - Phone:252-412-3207
Mailing Address - Street 1:PO BOX 2899
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27836-0899
Mailing Address - Country:US
Mailing Address - Phone:252-412-3207
Mailing Address - Fax:252-689-2996
Practice Address - Street 1:925D CONFERENCE DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5971
Practice Address - Country:US
Practice Address - Phone:252-412-3207
Practice Address - Fax:252-689-2996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-2786101YA0400X
NCC0093461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty