Provider Demographics
NPI:1649947912
Name:BLACKBURN, BRADLEY (LCMHC-A, NCC)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:LCMHC-A, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1792
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28026-1792
Mailing Address - Country:US
Mailing Address - Phone:704-918-5584
Mailing Address - Fax:833-552-2077
Practice Address - Street 1:23 UNION ST N STE A
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4726
Practice Address - Country:US
Practice Address - Phone:704-918-5584
Practice Address - Fax:833-552-2077
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA16749101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional