Provider Demographics
NPI:1851065072
Name:JUSTINE F. BRADLEY, LPC, LLC
Entity Type:Organization
Organization Name:JUSTINE F. BRADLEY, LPC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTINE
Authorized Official - Middle Name:F
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:276-285-5203
Mailing Address - Street 1:110 BRUNSWICK LN
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-3339
Mailing Address - Country:US
Mailing Address - Phone:276-285-5203
Mailing Address - Fax:276-285-5455
Practice Address - Street 1:110 BRUNSWICK LN
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-3339
Practice Address - Country:US
Practice Address - Phone:276-285-5203
Practice Address - Fax:276-285-5455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health