Provider Demographics
NPI:1992441745
Name:BRADFORD, BRITTNAY TAMARIS
Entity type:Individual
Prefix:
First Name:BRITTNAY
Middle Name:TAMARIS
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 1:1804 JAMESTOWN RD APT 4
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-6459
Mailing Address - Country:US
Mailing Address - Phone:256-282-7083
Mailing Address - Fax:
Practice Address - Street 1:11358 VAN CLEVE AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63114-1131
Practice Address - Country:US
Practice Address - Phone:314-710-1410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO824394223Medicaid