MEDICARE: ANDREA BULLOCK BRADLEY ED.S., LPC

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	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor	5277	SC

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	:	1952551426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA BULLOCK BRADLEY ED.S., LPC

Provider Business Mailing Address
First Line	:	4500 FORT JACKSON BLVD STE 110
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29209-1134
Country	:	US
Telephone Number	:	803-216-1107
Fax Number	:

Provider Business Practice Location Address
First Line	:	4500 FORT JACKSON BLVD STE 110
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29209-1134
Country	:	US
Telephone Number	:	803-216-1107
Fax Number	:

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

Provider Enumeration Date	:	09/22/2008
Last Update Date	:	09/23/2021

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