Healthcare Provider Details

I. General information

NPI: 1740960673
Provider Name (Legal Business Name): KELLI JO BRADFORD PEER SUPPRT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2023
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 LEDGERWOODS DR
AMELIA OH
45102-1700
US

IV. Provider business mailing address

76 LEDGERWOODS DR
AMELIA OH
45102-1700
US

V. Phone/Fax

Practice location:
  • Phone: 513-767-1038
  • Fax:
Mailing address:
  • Phone: 513-767-1038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.006258
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: