Provider Demographics
NPI:1396216404
Name:HIGGINBOTHAM, BRADLEY (MSSA)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:HIGGINBOTHAM
Suffix:
Gender:M
Credentials:MSSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-5967
Mailing Address - Country:US
Mailing Address - Phone:337-304-3719
Mailing Address - Fax:
Practice Address - Street 1:145 VICTORIA DR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70611-4641
Practice Address - Country:US
Practice Address - Phone:337-855-9773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)