Healthcare Provider Details

I. General information

NPI: 1851065072
Provider Name (Legal Business Name): JUSTINE F. BRADLEY, LPC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BRUNSWICK LN
MARION VA
24354-3339
US

IV. Provider business mailing address

110 BRUNSWICK LN
MARION VA
24354-3339
US

V. Phone/Fax

Practice location:
  • Phone: 276-285-5203
  • Fax: 276-285-5455
Mailing address:
  • Phone: 276-285-5203
  • Fax: 276-285-5455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JUSTINE F BRADLEY
Title or Position: OWNER/MEMBER
Credential: LPC
Phone: 276-285-5203