Provider Demographics
NPI:1376731158
Name:BRADLEY, RONNIE JOE (LCAS)
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:JOE
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 REMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5013
Mailing Address - Country:US
Mailing Address - Phone:704-332-9001
Mailing Address - Fax:704-295-4937
Practice Address - Street 1:145 REMOUNT RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5013
Practice Address - Country:US
Practice Address - Phone:704-332-9001
Practice Address - Fax:704-295-4937
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2007-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8300412101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)