Datrese Monique Bradley, LCPC

Primary specialty

Professional CounselorTaxonomy code 101YP2500X

License

180.014457 Issued in IL

Practice address

103 N Rod LN
Carbondale, IL 62901-2031

Phone

(618) 203-6925

NPI assigned

May 22, 2022

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in IL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Mental Health Specialty Group PA

  • Mental Health Counselor
  • Durham, NC
  • NPI 1801472634

  IL, Professional

  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1653177600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1653177600000",
    "number": "1053059949",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "103 N ROD LN",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629012031",
            "telephone_number": "618-203-6925"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "103 N ROD LN",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629012031",
            "telephone_number": "618-203-6925"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BRADLEY",
        "first_name": "DATRESE",
        "middle_name": "MONIQUE",
        "credential": "LCPC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-05-22",
        "last_updated": "2022-05-22",
        "certification_date": "2022-05-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": "IL",
            "license": "180.014457",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "dbradley58@siumed.edu",
            "affiliation": "N",
            "endpointDescription": "SIU Email",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "CSV",
            "contentTypeDescription": "CSV",
            "address_1": "103 N Rod Ln",
            "city": "Carbondale",
            "state": "IL",
            "country_code": "US",
            "postal_code": "629012031",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Mary L Brandenburg, PA
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• Brigham Anesthesia South LLC
• Jayda Brink

• Professional Counselor in Carbondale, IL
• Providers in Carbondale, IL by specialty
• Professional Counselor in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 22, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.