Basic Information
| Provider Information | |||||||||
| NPI: | 1720315187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LISW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4761 STATE RT 29 | ||||||||
| Address2: | FOUNDATIONS BEHAVIORAL HEALTH SERVICES INC | ||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195841000 | ||||||||
| FaxNumber: | 4195841825 | ||||||||
| Practice Location | |||||||||
| Address1: | 4761 STATE ROUTE 29 | ||||||||
| Address2: | |||||||||
| City: | CELINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4195841000 | ||||||||
| FaxNumber: | 4195841825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2009 | ||||||||
| LastUpdateDate: | 04/01/2015 | ||||||||
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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 | 104100000X | S.0500072 | OH | N | Behavioral Health & Social Service Providers | Social Worker | 101Y00000X | I.1302359 | OH | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.