Provider Demographics
NPI:1528576766
Name:BRADLEY, RANDALL LEE (LPCC, LCDCIII)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:LEE
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LPCC, LCDCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 BELL ST
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1720
Mailing Address - Country:US
Mailing Address - Phone:740-454-9766
Mailing Address - Fax:740-588-6452
Practice Address - Street 1:2845 BELL ST
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701
Practice Address - Country:US
Practice Address - Phone:740-454-9766
Practice Address - Fax:740-588-6452
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH081186101YA0400X
OHC.0701120101YM0800X
OHE.1800711101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0263277Medicaid