Provider Demographics
NPI:1720315187
Name:BRADLEY, AMY J (LISW)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4761 STATE RT 29
Mailing Address - Street 2:FOUNDATIONS BEHAVIORAL HEALTH SERVICES INC
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822
Mailing Address - Country:US
Mailing Address - Phone:419-584-1000
Mailing Address - Fax:419-584-1825
Practice Address - Street 1:4761 STATE ROUTE 29
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822
Practice Address - Country:US
Practice Address - Phone:419-584-1000
Practice Address - Fax:419-584-1825
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.0500072104100000X
OHI.1302359101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker