MEDICARE: KESHA L BRADFORD MSW, LGSW

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	101YP2500X	Professional Counselor	29289	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235746579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KESHA L BRADFORD MSW, LGSW

Provider Business Mailing Address
First Line	:	4315 IRVING AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55412-1258
Country	:	US
Telephone Number	:	612-703-2618
Fax Number	:

Provider Business Practice Location Address
First Line	:	4315 IRVING AVE N
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55412-1258
Country	:	US
Telephone Number	:	612-703-2618
Fax Number	:

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

Provider Enumeration Date	:	09/30/2020
Last Update Date	:	11/27/2023

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