Doctor Name: | MR. BRADLEY KEBODEAUX |
NPI Number: | 1447577002 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | |
License Number: | |
Business Practice Address: | 2100 E Chambers Dr Booneville, MS - 388298938 |
Business Phone Number: | 6627283174 |
Business Fax Number: | 6627283175 |
Mailing Address: | 303 N Madison St, CORINTH |
State: | MS |
Postal Code: | 388345072 |
Phone Number: | 6622869883 |
Fax Number: | 6622868095 |
NPI Enumeration Date: | 04/22/2010 |
NPI Last Update Date: | 04/22/2010 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YM0800X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Mental Health |
Taxonomy Definition: |