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NPI Code Detail

MEDICARE: IRENE LOUISE BRADFORD

MEDICARE: IRENE LOUISE BRADFORD
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
1103K00000XBehavior Analyst101Y00000X-COUNSELORUT
21041C0700XClinical Social Worker9466365-3501UT

General Provider Information

NPI Number : 1396043857
Entity Type Code : Individual
Provider Name (Legal Business Name) : IRENE LOUISE BRADFORD
Provider Business Mailing Address
First Line : PO BOX 572070
Second Line :
City : MURRAY
State : UT
Zip : 84157-2070
Country : US
Telephone Number : 801-263-7100
Fax Number :
Provider Business Practice Location Address
First Line : 1020 S MAIN ST STE 100
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84101-3194
Country : US
Telephone Number : 888-948-4864
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/08/2011
Last Update Date : 11/09/2018

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Directions to “ IRENE LOUISE BRADFORD ” Practice Location

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