Provider Demographics
NPI:1811270424
Name:BREDY, POLLY (M ED LPC)
Entity type:Individual
Prefix:MRS
First Name:POLLY
Middle Name:
Last Name:BREDY
Suffix:
Gender:F
Credentials:M ED LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15135 N 2330 RD
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:OK
Mailing Address - Zip Code:73564-4023
Mailing Address - Country:US
Mailing Address - Phone:580-331-8727
Mailing Address - Fax:
Practice Address - Street 1:901 S BROADWAY
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:OK
Practice Address - Zip Code:73651-1834
Practice Address - Country:US
Practice Address - Phone:580-726-3383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2535101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100707910BMedicaid