Provider Demographics
NPI:1811235989
Name:KORNEGAY, BRADLEY EDWARD (MSW, LCSW, LCAS)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:EDWARD
Last Name:KORNEGAY
Suffix:
Gender:M
Credentials:MSW, LCSW, LCAS
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 2899
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27836-0899
Mailing Address - Country:US
Mailing Address - Phone:252-412-3201
Mailing Address - Fax:
Practice Address - Street 1:925 CONFERENCE DR
Practice Address - Street 2:SUITE D
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5971
Practice Address - Country:US
Practice Address - Phone:252-412-3207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0093461041C0700X
NCLCAS -2786101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)