Provider Demographics
NPI:1548714777
Name:BRADLEY, TERESA (LPC, NCC, MAC,)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LPC, NCC, MAC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 BRADFORD SQ STE A
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30215-1902
Mailing Address - Country:US
Mailing Address - Phone:678-683-8435
Mailing Address - Fax:
Practice Address - Street 1:135 BRADFORD SQ STE A
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30215-1902
Practice Address - Country:US
Practice Address - Phone:678-489-8072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA010087101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional