Provider Demographics
NPI:1003535311
Name:BRADLEY, BETHANY LEIGH (LCSW)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:LEIGH
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 1:4142 GREEN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-0701
Mailing Address - Country:US
Mailing Address - Phone:325-716-7718
Mailing Address - Fax:
Practice Address - Street 1:4142 GREEN MEADOW DR
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-0701
Practice Address - Country:US
Practice Address - Phone:325-716-7718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX685951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical