Healthcare Provider Details

I. General information

NPI: 1962110056
Provider Name (Legal Business Name): GLEN ROBERT HARDBECK BRADLEY MA, LGPC (DC)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 ONTARIO RD NW
WASHINGTON DC
20009-2627
US

IV. Provider business mailing address

1835 7TH ST NW # 230
WASHINGTON DC
20001-3107
US

V. Phone/Fax

Practice location:
  • Phone: 202-483-8196
  • Fax:
Mailing address:
  • Phone: 816-286-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGPC200001455
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: