Provider Demographics
NPI:1578052486
Name:BRADLEY, KYANA (LPC, LCPC)
Entity Type:Individual
Prefix:
First Name:KYANA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LPC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 4TH ST APT D
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8101 SANDY SPRING RD STE 250
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-3527
Practice Address - Country:US
Practice Address - Phone:202-344-7933
Practice Address - Fax:240-366-5750
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-07
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC8316101Y00000X, 101YP2500X, 101YM0800X
DCPRC14889101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD907084200Medicaid