Provider Demographics
NPI:1366119927
Name:BRADBURY, NICOLE MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:BRADBURY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 W 7TH ST STE 900
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78701-3013
Mailing Address - Country:US
Mailing Address - Phone:512-838-4264
Mailing Address - Fax:
Practice Address - Street 1:8 E COTTONWOOD ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4382
Practice Address - Country:US
Practice Address - Phone:928-634-2236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ201831041C0700X
MELC237321041C0700X
TX670131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical