Healthcare Provider Details

I. General information

NPI: 1962117762
Provider Name (Legal Business Name): BRIA BRADFORD LCSWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2023
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 FAIR MEADOWS LN STE 102
RALEIGH NC
27607-6449
US

IV. Provider business mailing address

2587 RAVENHILL DR
FAYETTEVILLE NC
28303-5451
US

V. Phone/Fax

Practice location:
  • Phone: 919-670-3939
  • Fax: 910-483-2026
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP014121
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: