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General NPI Number Information
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NPI Number | 1225422686
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Entity Type | Organization
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Legal Business Name | BRADLEY KORNEGAY, LCSW, LCAS, PLLC
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Dates
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Enumeration Date | 03/24/2015
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Last Update Date | 03/24/2015
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Provider Practice Location Address
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Address Line | 925D CONFERENCE DR
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City | GREENVILLE
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State | NC
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Zip | 27858-5971
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Country | US
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Telephone | 252-412-3207
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Fax | 252-689-2996
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Provider Business Mailing Address
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Address Line | PO BOX 2899
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City | GREENVILLE
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State | NC
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Zip | 27836-0899
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Country | US
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Telephone | 252-412-3207
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Fax | 252-689-2996
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Authorized Official
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Title or Position | OWNER
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Name | BRADLEY KORNEGAY
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Credential | MSW, LCSW, LCAS
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Telephone | 252-412-3207
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | LCAS-2786
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | C009346
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License Number State | NC
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