Healthcare Provider Details

I. General information

NPI: 1184468472
Provider Name (Legal Business Name): TABATHA BRADLEY LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2024
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 MISSISSIPPI ST S
WYNNE AR
72396-3025
US

IV. Provider business mailing address

204 MISSISSIPPI ST S
WYNNE AR
72396-3025
US

V. Phone/Fax

Practice location:
  • Phone: 870-208-8499
  • Fax:
Mailing address:
  • Phone: 870-208-8499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP2608004
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberA2406004
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: