Provider Demographics
NPI:1023789344
Name:BRADLEY, DE'ERIK LAMONTAE (LCSWA)
Entity type:Individual
Prefix:
First Name:DE'ERIK
Middle Name:LAMONTAE
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 EAST BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5156
Mailing Address - Country:US
Mailing Address - Phone:704-980-3082
Mailing Address - Fax:704-980-3082
Practice Address - Street 1:2901 COLTSGATE RD STE 202
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4384
Practice Address - Country:US
Practice Address - Phone:704-980-3082
Practice Address - Fax:704-980-3082
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2023-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPO152731041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical