Provider Demographics
NPI:1750666152
Name:BRADLEY, DIANNE M (LCSW)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:M
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 1:121 LAVENIA LN
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:KY
Mailing Address - Zip Code:42757-7823
Mailing Address - Country:US
Mailing Address - Phone:423-817-8818
Mailing Address - Fax:
Practice Address - Street 1:100 PAR LN STE 102
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-9059
Practice Address - Country:US
Practice Address - Phone:423-817-8818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040084131041C0700X
TN58371041C0700X
DCLC500811031041C0700X
KY2564191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100822370Medicaid