Provider Demographics
NPI:1477314276
Name:SMITH, BRADLEY ALLEN (LPC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:ALLEN
Last Name:SMITH
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:PO BOX 282
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62565-0282
Mailing Address - Country:US
Mailing Address - Phone:281-745-2708
Mailing Address - Fax:
Practice Address - Street 1:7280 NW 87TH TER STE C-210
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64153-3720
Practice Address - Country:US
Practice Address - Phone:646-453-6777
Practice Address - Fax:212-337-9841
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022045313101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty