Provider Demographics
NPI:1790445153
Name:ELLIS, BRADLEY SCOTT (LPC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:SCOTT
Last Name:ELLIS
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 BROAD BRANCH LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23238-6452
Mailing Address - Country:US
Mailing Address - Phone:804-592-6344
Mailing Address - Fax:
Practice Address - Street 1:6800 PARAGON PL STE 420
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23230-1652
Practice Address - Country:US
Practice Address - Phone:804-239-7688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional