Provider Demographics
NPI:1962534891
Name:BRADFORD, CAROL CORINNE (LMP)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:CORINNE
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 89
Mailing Address - Street 2:
Mailing Address - City:KENDRICK
Mailing Address - State:ID
Mailing Address - Zip Code:83537-0089
Mailing Address - Country:US
Mailing Address - Phone:208-883-5856
Mailing Address - Fax:208-289-5211
Practice Address - Street 1:106 E 3RD ST
Practice Address - Street 2:SUITE 5A
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2970
Practice Address - Country:US
Practice Address - Phone:208-883-5856
Practice Address - Fax:208-289-5211
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA024201MA00015161225700000X
ID034956-00225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist