Provider Demographics
NPI:1881037042
Name:BRADLEY, LESLIE (MA, LCSW, PMH-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MA, LCSW, PMH-C
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:WHALEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LCSW, PMH-C
Mailing Address - Street 1:714 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-3843
Mailing Address - Country:US
Mailing Address - Phone:331-253-7782
Mailing Address - Fax:
Practice Address - Street 1:1761 S NAPERVILLE RD STE 103
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-5846
Practice Address - Country:US
Practice Address - Phone:630-635-0591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011163201041C0700X
COCSW.099246551041C0700X
IL149.0146231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty