Provider Demographics
NPI:1952928871
Name:IMLER, P BRAD (LCSW, PHD)
Entity Type:Individual
Prefix:
First Name:P
Middle Name:BRAD
Last Name:IMLER
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1931 BRENTON ST
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-3553
Mailing Address - Country:US
Mailing Address - Phone:214-808-5798
Mailing Address - Fax:
Practice Address - Street 1:1931 BRENTON ST
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-3553
Practice Address - Country:US
Practice Address - Phone:214-808-5798
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX252121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical