MEDICARE: MRS. MICHELE NICOLE BRADFORD LMFT

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	106H00000X	Marriage & Family Therapist	MT4540	FL

General Provider Information

NPI Number	:	1205184660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELE NICOLE BRADFORD LMFT

Provider Business Mailing Address
First Line	:	2573 MINOSA CIR N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-2463
Country	:	US
Telephone Number	:	904-705-3400
Fax Number	:

Provider Business Practice Location Address
First Line	:	2573 MINOSA CIR N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-2463
Country	:	US
Telephone Number	:	904-705-3400
Fax Number	:

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

Provider Enumeration Date	:	08/16/2012
Last Update Date	:	01/23/2023

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