Provider Demographics
NPI:1851557409
Name:BRADLEY, CHARLES GLENN (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:GLENN
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 LOVERN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-1761
Mailing Address - Country:US
Mailing Address - Phone:606-438-5649
Mailing Address - Fax:606-714-0500
Practice Address - Street 1:213 LOVERN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-1761
Practice Address - Country:US
Practice Address - Phone:606-438-5649
Practice Address - Fax:606-714-0500
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical