Healthcare Provider Details

I. General information

NPI: 1275711301
Provider Name (Legal Business Name): KATHLEEN BRADFORD LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2008
Last Update Date: 01/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 FAIRVIEW AVE STE. 235
MISSOULA MT
59801-0235
US

IV. Provider business mailing address

1515 FAIRVIEW AVE. STE. 235
MISSOULA MT
59801-0235
US

V. Phone/Fax

Practice location:
  • Phone: 406-721-5157
  • Fax: 406-327-1215
Mailing address:
  • Phone: 406-721-5157
  • Fax: 406-327-1215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1316
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: