Healthcare Provider Details

I. General information

NPI: 1487297511
Provider Name (Legal Business Name): WILLIAM MICHEAL BRADFORD LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 W 32ND ST
PUEBLO CO
81008-1313
US

IV. Provider business mailing address

131 EAGLE CREST LOOP
CANON CITY CO
81212-9698
US

V. Phone/Fax

Practice location:
  • Phone: 719-565-8829
  • Fax:
Mailing address:
  • Phone: 719-565-8829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberACD0002279
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: