Basic Information
| Provider Information | |||||||||
| NPI: | 1962110056 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | ROBERT HARDBECK | ||||||||
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| Credential: | MA, LGPC (DC) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1835 7TH ST NW # 230 | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200013107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162866555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2333 ONTARIO RD NW | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200092627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2024838196 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2022 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | LGPC200001455 | DC | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.