Provider Demographics
NPI:1578741898
Name:BRADLEY CLEVELAND REHAB SERVICES
Entity Type:Organization
Organization Name:BRADLEY CLEVELAND REHAB SERVICES
Other - Org Name:YOUTH COUNSELING SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:CHAIRMAN OF BOARD
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:KIE
Authorized Official - Last Name:VINING
Authorized Official - Suffix:
Authorized Official - Credentials:DMIN, LPC
Authorized Official - Phone:423-476-1933
Mailing Address - Street 1:423 CENTRAL AVE NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-4923
Mailing Address - Country:US
Mailing Address - Phone:423-476-1933
Mailing Address - Fax:423-559-1848
Practice Address - Street 1:423 CENTRAL AVE NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-4923
Practice Address - Country:US
Practice Address - Phone:423-476-1933
Practice Address - Fax:423-559-1848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-08
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL214-117-2195251S00000X
TNLPC0000000694251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5442187Medicaid