MEDICARE: MS. ANITRA LYNETTE BRADFORD LAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	A0710078	AR
2	101YP2500X	Professional Counselor	P1012084	AR

General Provider Information

NPI Number	:	1124218177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANITRA LYNETTE BRADFORD LAC

Provider Business Mailing Address
First Line	:	1600 ALDERSGATE RD STE 200
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-6676
Country	:	US
Telephone Number	:	501-661-0720
Fax Number	:

Provider Business Practice Location Address
First Line	:	621 E NORTH ST
Second Line	:
City	:	MAGNOLIA
State	:	AR
Zip	:	71753-3120
Country	:	US
Telephone Number	:	870-234-0739
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2007
Last Update Date	:	03/17/2018

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