Provider Demographics
NPI:1124850888
Name:BRADFORD, ALYSSA MADISON
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:MADISON
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1438 RIVA DEL GARDA WAY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-3404
Mailing Address - Country:US
Mailing Address - Phone:904-392-7345
Mailing Address - Fax:
Practice Address - Street 1:3408 S ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH SHORES
Practice Address - State:FL
Practice Address - Zip Code:32118-6311
Practice Address - Country:US
Practice Address - Phone:386-767-3752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-20
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician