Provider Demographics
NPI:1417912304
Name:HEAD, BRADLEY MARVIN (LPC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:MARVIN
Last Name:HEAD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:BRAD
Other - Middle Name:M
Other - Last Name:HEAD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:2550 SHOW LOW LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7929
Mailing Address - Country:US
Mailing Address - Phone:928-537-1029
Mailing Address - Fax:928-537-9049
Practice Address - Street 1:2550 SHOW LOW LAKE ROAD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7929
Practice Address - Country:US
Practice Address - Phone:928-537-1029
Practice Address - Fax:928-537-9049
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC0637101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ742488OtherAHCCCS