=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992844617
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH MCGINTY BRADLEY LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 12/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3455 LAWRENCEVILLE SUWANEE RD STE A
-----------------------------------------------------
City | SUWANEE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30024-6425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-622-7154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1080 SECRET COVE DR
-----------------------------------------------------
City | SUGAR HILL
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30518-5300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-622-7154
-----------------------------------------------------
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 | LPC2551
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC005367
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------