Healthcare Provider Details

I. General information

NPI: 1336679471
Provider Name (Legal Business Name): BRADLEY GIFFORD LCDC III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 S MARTIN LUTHER KING JR BLVD
HAMILTON OH
45011-3216
US

IV. Provider business mailing address

820 S MARTIN LUTHER KING JR BLVD
HAMILTON OH
45011-3216
US

V. Phone/Fax

Practice location:
  • Phone: 513-887-8500
  • Fax: 513-737-8196
Mailing address:
  • Phone: 513-887-8500
  • Fax: 513-737-8196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCDC141099-3
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: