Provider Demographics
NPI:1043050354
Name:BRADLEY, BLAKE MORGAN (LPCC)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:MORGAN
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6760 CORPORATE DR STE 140
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-5910
Mailing Address - Country:US
Mailing Address - Phone:251-656-5244
Mailing Address - Fax:
Practice Address - Street 1:6760 CORPORATE DR STE 140
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80919-5910
Practice Address - Country:US
Practice Address - Phone:251-656-5244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0022066101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional