MEDICARE: SHALON BRADLEY LPC, BC-TMH

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	101YP2500X	Professional Counselor	2107	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790166601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHALON BRADLEY LPC, BC-TMH

Provider Business Mailing Address
First Line	:	108 ESTES ST
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39503-3208
Country	:	US
Telephone Number	:	228-300-2425
Fax Number	:	228-265-8117

Provider Business Practice Location Address
First Line	:	1907 PASS RD STE D
Second Line	:
City	:	BILOXI
State	:	MS
Zip	:	39531-4101
Country	:	US
Telephone Number	:	228-300-2425
Fax Number	:	228-265-8117

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2015
Last Update Date	:	06/15/2021

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