Provider Demographics
NPI:1649880170
Name:SANSOM, BRADLEY ALLEN (MS, CADC)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:ALLEN
Last Name:SANSOM
Suffix:
Gender:M
Credentials:MS, CADC
Other - Prefix:MR
Other - First Name:BRADLEY
Other - Middle Name:ALLEN
Other - Last Name:SANSOM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CADC
Mailing Address - Street 1:628 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1471
Mailing Address - Country:US
Mailing Address - Phone:606-789-6966
Mailing Address - Fax:606-789-7466
Practice Address - Street 1:628 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1471
Practice Address - Country:US
Practice Address - Phone:606-789-6966
Practice Address - Fax:606-789-7466
Is Sole Proprietor?:No
Enumeration Date:2020-08-10
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY244702101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)