MEDICARE: BRADLEY COUNSELING CENTERS LICENSED CLINICAL SOCIAL WORKER CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LW11249	CA

General Provider Information

NPI Number	:	1275979932
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRADLEY COUNSELING CENTERS LICENSED CLINICAL SOCIAL WORKER CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 27065
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93729-7065
Country	:	US
Telephone Number	:	559-916-7585
Fax Number	:	559-230-1799

Provider Business Practice Location Address
First Line	:	2519 W SHAW AVE
Second Line	:	SUITE #100
City	:	FRESNO
State	:	CA
Zip	:	93711-3311
Country	:	US
Telephone Number	:	559-230-1008
Fax Number	:	559-230-1799

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SALLIE MAE BRADLEY
Credential	:	LCSW
Telephone Number	:	559-916-7585

Provider Enumeration Date	:	05/21/2013
Last Update Date	:	03/28/2014

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