Basic Information
| Provider Information | |||||||||
| NPI: | 1972831188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | GLENETTA | ||||||||
| MiddleName: | LASCHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 502 N 14TH ST | ||||||||
| Address2: | |||||||||
| City: | PERRY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730775022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183085512 | ||||||||
| FaxNumber: | 5802155767 | ||||||||
| Practice Location | |||||||||
| Address1: | 502 N 14TH ST | ||||||||
| Address2: | |||||||||
| City: | PERRY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730775022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183085512 | ||||||||
| FaxNumber: | 5802155767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2009 | ||||||||
| LastUpdateDate: | 03/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 7104 | OK | N | Behavioral Health & Social Service Providers | Social Worker | 103K00000X | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 7104 | 01 | OK | LCSW | OTHER |