Healthcare Provider Details

I. General information

NPI: 1760300701
Provider Name (Legal Business Name): HOLLY ANN BRADFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 HISTORIC 66 W STE 101
WAYNESVILLE MO
65583-8322
US

IV. Provider business mailing address

22272 REBEL LN
WAYNESVILLE MO
65583-2829
US

V. Phone/Fax

Practice location:
  • Phone: 573-433-4846
  • Fax:
Mailing address:
  • Phone: 240-751-5335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: