Provider Demographics
NPI:1568959245
Name:OGLETREE, BRADLEY JR
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:OGLETREE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-5434
Mailing Address - Country:US
Mailing Address - Phone:706-687-6701
Mailing Address - Fax:
Practice Address - Street 1:3601 HILTON AVE STE 225
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-7373
Practice Address - Country:US
Practice Address - Phone:706-464-1300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007106101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty