Provider Demographics
NPI:1447577002
Name:KEBODEAUX, BRADLEY (LPC)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:KEBODEAUX
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-5072
Mailing Address - Country:US
Mailing Address - Phone:662-286-9883
Mailing Address - Fax:662-286-8095
Practice Address - Street 1:2100 E CHAMBERS DR
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-8938
Practice Address - Country:US
Practice Address - Phone:662-728-3174
Practice Address - Fax:662-728-3175
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-22
Last Update Date:2016-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MS1633101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health