Provider Demographics
NPI:1669872107
Name:BEATTY, BRADLEY JACK (LICDC-CS)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:JACK
Last Name:BEATTY
Suffix:
Gender:M
Credentials:LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3767 RICHARD AVE
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-2417
Mailing Address - Country:US
Mailing Address - Phone:614-877-2441
Mailing Address - Fax:
Practice Address - Street 1:3767 RICHARD AVE
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-2417
Practice Address - Country:US
Practice Address - Phone:614-877-2441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH910395101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)