Provider Demographics
NPI:1285640581
Name:BRADLEY, LEONARD EUGENE (MSE, CCDP-D, ICCDP-D)
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:EUGENE
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:MSE, CCDP-D, ICCDP-D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 703
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-0703
Mailing Address - Country:US
Mailing Address - Phone:314-574-4081
Mailing Address - Fax:
Practice Address - Street 1:9167 W FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-1420
Practice Address - Country:US
Practice Address - Phone:314-547-4081
Practice Address - Fax:314-524-3804
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X, 101YM0800X
MO4917101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health