Provider Demographics
NPI:1770687717
Name:LORD, BRADLEY WAYNE (PSYD MS LMHC CAP)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:WAYNE
Last Name:LORD
Suffix:
Gender:M
Credentials:PSYD MS LMHC CAP
Other - Prefix:DR
Other - First Name:BRAD
Other - Middle Name:WAYNE
Other - Last Name:LORD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD MS LMHC CAP
Mailing Address - Street 1:1221 W LAKEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-1836
Mailing Address - Country:US
Mailing Address - Phone:850-469-3500
Mailing Address - Fax:850-595-1400
Practice Address - Street 1:1221 W LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-1836
Practice Address - Country:US
Practice Address - Phone:850-469-3500
Practice Address - Fax:850-595-1400
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8489101YM0800X, 101YM0800X, 101YP2500X
FLCAP 2585101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766852000Medicare ID - Type UnspecifiedLMHC CAP