Healthcare Provider Details

I. General information

NPI: 1225469919
Provider Name (Legal Business Name): BRADLEY KOCHUNAS PCC-S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2013
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1131 MANCHESTER AVE
MIDDLETOWN OH
45042-1925
US

IV. Provider business mailing address

1490 UNIVERSITY BLVD
HAMILTON OH
45011-3305
US

V. Phone/Fax

Practice location:
  • Phone: 513-422-7016
  • Fax: 513-422-5682
Mailing address:
  • Phone: 513-881-7189
  • Fax: 513-881-7188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberE2212
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: