Healthcare Provider Details

I. General information

NPI: 1174862320
Provider Name (Legal Business Name): BRAD T BROGDON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 N COMMERCE ST
ARDMORE OK
73401-1268
US

IV. Provider business mailing address

2706 E HARBERT RD
TISHOMINGO OK
73460-4035
US

V. Phone/Fax

Practice location:
  • Phone: 580-223-5636
  • Fax:
Mailing address:
  • Phone: 580-310-8105
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6840
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: