Provider Demographics
NPI:1609171966
Name:BRADLEY, MARY A (LSCSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:A
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LSCSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6511 W 80TH ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66204-3811
Mailing Address - Country:US
Mailing Address - Phone:913-710-9480
Mailing Address - Fax:
Practice Address - Street 1:4010 WASHINGTON ST
Practice Address - Street 2:SUITE 405
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-2609
Practice Address - Country:US
Practice Address - Phone:913-710-9480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-18
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS40261041C0700X
MO20110220831041C0700X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities