Provider Demographics
NPI:1972831188
Name:BRADLEY, GLENETTA LASCHELLE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GLENETTA
Middle Name:LASCHELLE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 N 14TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-5022
Mailing Address - Country:US
Mailing Address - Phone:918-308-5512
Mailing Address - Fax:580-215-5767
Practice Address - Street 1:502 N 14TH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-5022
Practice Address - Country:US
Practice Address - Phone:918-308-5512
Practice Address - Fax:580-215-5767
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-28
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7104104100000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK7104OtherLCSW