Provider Demographics
NPI:1669859385
Name:BRADLEY, CONNIE G (LCSW)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:G
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 408
Mailing Address - Street 2:
Mailing Address - City:WARTBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37887-0408
Mailing Address - Country:US
Mailing Address - Phone:423-346-6221
Mailing Address - Fax:423-346-5565
Practice Address - Street 1:224 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:WARTBURG
Practice Address - State:TN
Practice Address - Zip Code:37887-4163
Practice Address - Country:US
Practice Address - Phone:423-346-6221
Practice Address - Fax:423-346-5565
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10355104100000X
TN75171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker