Basic Information
| Provider Information | |||||||||
| NPI: | 1639618473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | DANSBY | ||||||||
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| OtherLastName: | DANSBY | ||||||||
| OtherFirstName: | LACEY | ||||||||
| OtherMiddleName: | DAWN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13808 NE 10TH ST | ||||||||
| Address2: | |||||||||
| City: | CHOCTAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730208117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055032827 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4300 N LINCOLN BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731055107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054250364 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2017 | ||||||||
| LastUpdateDate: | 02/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.