Provider Demographics
NPI:1982708665
Name:BRADLEY, ANGELIA PINCKARD (MED LPC MHSP)
Entity Type:Individual
Prefix:
First Name:ANGELIA
Middle Name:PINCKARD
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MED LPC MHSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 JOE HALE DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-3866
Mailing Address - Country:US
Mailing Address - Phone:423-677-7824
Mailing Address - Fax:
Practice Address - Street 1:210 JOE HALE DR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-3866
Practice Address - Country:US
Practice Address - Phone:423-677-7824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLPCMHSP2004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
620582605OtherCARITEN PHP PPO
620582605OtherTRICARE SOUTH
620582605OtherTHREE RIVERS PROVI GROUP
620582605OtherCORPHEALTH
620582605OtherINITIAL GROUP GROUP
620582605OtherCARITEN SENIOR PPO
620582605OtherCARITEN SENIOR HMO
4120940OtherMAGELLAN SUMMIT
010277582OtherVIRGINIA MEDICAID CTC
4120940OtherMAGELLAN NAVIGATOR
620582605OtherCARITEN PHP HMO
620582605OtherCARITEN PHP WORKCO
334969OtherVALUEOPTIONS GROUP
4120940OtherMAGELLAN PINNACLE
9427660OtherPHCS
620582605OtherCARITEN PHP POS
620582605OtherCARITEN PPO LEASE