=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174862320
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRAD T BROGDON LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2013
-----------------------------------------------------
Last Update Date | 12/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2007 N COMMERCE ST
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-1268
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-223-5636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2706 E HARBERT RD
-----------------------------------------------------
City | TISHOMINGO
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73460-4035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-310-8105
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6840
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------