1982708665 NPI number — ANGELIA PINCKARD BRADLEY MED LPC MHSP

Table of content: ANGELIA PINCKARD BRADLEY MED LPC MHSP (NPI 1982708665)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982708665 NPI number — ANGELIA PINCKARD BRADLEY MED LPC MHSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
ANGELIA
Provider Middle Name:
PINCKARD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MED LPC MHSP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1982708665
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 JOE HALE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOHNSON CITY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37615-3866
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-677-7824
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 JOE HALE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37615-3866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-677-7824
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPCMHSP2004 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 620582605 . This is a "CARITEN PHP PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620582605 . This is a "TRICARE SOUTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620582605 . This is a "THREE RIVERS PROVI GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620582605 . This is a "CORPHEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620582605 . This is a "INITIAL GROUP GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620582605 . This is a "CARITEN SENIOR PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620582605 . This is a "CARITEN SENIOR HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4120940 . This is a "MAGELLAN SUMMIT" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010277582 . This is a "VIRGINIA MEDICAID CTC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4120940 . This is a "MAGELLAN NAVIGATOR" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620582605 . This is a "CARITEN PHP HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620582605 . This is a "CARITEN PHP WORKCO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 334969 . This is a "VALUEOPTIONS GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4120940 . This is a "MAGELLAN PINNACLE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9427660 . This is a "PHCS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620582605 . This is a "CARITEN PHP POS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 620582605 . This is a "CARITEN PPO LEASE" identifier . This identifiers is of the category "OTHER".




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