Provider Demographics
NPI:1972711596
Name:BRADFORD, LISA BAZZANO (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:BAZZANO
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:JEANNE
Other - Last Name:BAZZANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:3462 ESSEX AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5752
Mailing Address - Country:US
Mailing Address - Phone:678-612-6023
Mailing Address - Fax:770-980-1293
Practice Address - Street 1:3462 ESSEX AVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-5752
Practice Address - Country:US
Practice Address - Phone:678-612-6023
Practice Address - Fax:770-980-1293
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003520235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist