Healthcare Provider Details

I. General information

NPI: 1467119701
Provider Name (Legal Business Name): BRADEY DISBROW LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2021
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 WILFORD HALL LOOP
APO AA
78245
US

IV. Provider business mailing address

13214 LATTIGO BND
SAN ANTONIO TX
78245-5003
US

V. Phone/Fax

Practice location:
  • Phone: 605-351-7093
  • Fax:
Mailing address:
  • Phone: 605-351-7093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPCC.0018595
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: