Healthcare Provider Details

I. General information

NPI: 1922407337
Provider Name (Legal Business Name): KIMBERLY ANNETTE BRADLEY BSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 08/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10844 VICENZA DR NW
ALBUQUERQUE NM
87114-5279
US

IV. Provider business mailing address

10844 VICENZA DR NW
ALBUQUERQUE NM
87114-5279
US

V. Phone/Fax

Practice location:
  • Phone: 505-249-5398
  • Fax: 505-271-4957
Mailing address:
  • Phone: 505-249-5398
  • Fax: 505-271-4957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: