1790166601 NPI number — SHALON BRADLEY LPC, BC-TMH

Table of content: SHALON BRADLEY LPC, BC-TMH (NPI 1790166601)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790166601 NPI number — SHALON BRADLEY LPC, BC-TMH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
SHALON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC, BC-TMH
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:
1790166601
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
108 ESTES ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GULFPORT
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39503-3208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-300-2425
Provider Business Mailing Address Fax Number:
228-265-8117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1907 PASS RD STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BILOXI
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39531-4101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-300-2425
Provider Business Practice Location Address Fax Number:
228-265-8117
Provider Enumeration Date:
06/16/2015

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:  2107 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03908869 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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