Healthcare Provider Details

I. General information

NPI: 1710842844
Provider Name (Legal Business Name): BRADLEY JOHN REIS MA LPCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 WINDING ROCK RD
SIMPSONVILLE SC
29680-2486
US

IV. Provider business mailing address

129 WINDING ROCK RD
SIMPSONVILLE SC
29680-2486
US

V. Phone/Fax

Practice location:
  • Phone: 864-214-6519
  • Fax:
Mailing address:
  • Phone: 864-214-6519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10786
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: