Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor | 14527 | TX |
N | 101YP1600X | Pastoral Counselor | 14527 | TX |
N | 101YP2500X | Professional Counselor | 14527 | TX |
N | 101YS0200X | School Counselor | 14527 | TX |
NPI | 1063765246 |
---|---|
Provider Name | Mr. Rolla Merle Bradley JR. |
First Address | Garden Ridge, TX 78266-2060 |
Second Address | Garden Ridge, TX 78266-2060 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/10/2012 |
Last Update Date | 23/04/2018 |