Provider Demographics
NPI:1427351832
Name:BRADFORD, WANDA RENEE (PSYD)
Entity type:Individual
Prefix:DR
First Name:WANDA
Middle Name:RENEE
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4830 DARTRY DR
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-5294
Mailing Address - Country:US
Mailing Address - Phone:708-798-7861
Mailing Address - Fax:
Practice Address - Street 1:15020 S RAVINIA AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3166
Practice Address - Country:US
Practice Address - Phone:708-403-4055
Practice Address - Fax:708-403-2275
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.007613103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical