Healthcare Provider Details

I. General information

NPI: 1245163435
Provider Name (Legal Business Name): MS. ALISSA MONIQUE BRADFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2108 WOLTER AVE
SAINT LOUIS MO
63114-5920
US

IV. Provider business mailing address

2108 WOLTER AVE
SAINT LOUIS MO
63114-5920
US

V. Phone/Fax

Practice location:
  • Phone: 314-305-5113
  • Fax:
Mailing address:
  • Phone: 314-305-5113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number28063
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2024040434
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: