Healthcare Provider Details

I. General information

NPI: 1215340773
Provider Name (Legal Business Name): BRADLEY CARROLL MSW, LGSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2014
Last Update Date: 04/01/2025
Certification Date: 04/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8591 HOLLY MEADOWS RD
PARSONS WV
26287-8604
US

IV. Provider business mailing address

8591 HOLLY MEADOWS RD
PARSONS WV
26287-8604
US

V. Phone/Fax

Practice location:
  • Phone: 304-478-3339
  • Fax:
Mailing address:
  • Phone: 304-478-3339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberBP00947033
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number2012-2932
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberM04990
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: