MEDICARE: BRAD T BROGDON LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	6840	OK

General Provider Information

NPI Number	:	1174862320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRAD T BROGDON LPC

Provider Business Mailing Address
First Line	:	2706 E HARBERT RD
Second Line	:
City	:	TISHOMINGO
State	:	OK
Zip	:	73460-4035
Country	:	US
Telephone Number	:	580-310-8105
Fax Number	:

Provider Business Practice Location Address
First Line	:	2007 N COMMERCE ST
Second Line	:
City	:	ARDMORE
State	:	OK
Zip	:	73401-1268
Country	:	US
Telephone Number	:	580-223-5636
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2013
Last Update Date	:	12/20/2024

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