Provider Demographics
NPI:1053962662
Name:BRADLEY, SHANELL (LPC)
Entity type:Individual
Prefix:
First Name:SHANELL
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 N SAM HOUSTON PKWY E STE 155
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-4061
Mailing Address - Country:US
Mailing Address - Phone:832-943-4035
Mailing Address - Fax:
Practice Address - Street 1:6021 FAIRMONT PKWY STE 200
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-4511
Practice Address - Country:US
Practice Address - Phone:281-769-2238
Practice Address - Fax:281-769-2164
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-25
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX373188702Medicaid