Healthcare Provider Details

I. General information

NPI: 1831867654
Provider Name (Legal Business Name): LAURA BRADBURY LSCW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2021
Last Update Date: 09/06/2021
Certification Date: 09/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

549 N 200 W
BOUNTIFUL UT
84010-6955
US

IV. Provider business mailing address

549 N 200 W
BOUNTIFUL UT
84010-6955
US

V. Phone/Fax

Practice location:
  • Phone: 801-540-8018
  • Fax:
Mailing address:
  • Phone: 801-540-8018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11822772-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: