Provider Demographics
NPI:1982262465
Name:BRADLEY, ANGELICA (LPCC)
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 CHAMPION WAY STE 11
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-8862
Mailing Address - Country:US
Mailing Address - Phone:502-603-0020
Mailing Address - Fax:
Practice Address - Street 1:205 CHAMPION WAY STE 11
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8862
Practice Address - Country:US
Practice Address - Phone:502-603-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
KY288971101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator