MEDICARE: MS. MISSY ALLEN BRADBURN

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	104100000X	Social Worker
2	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1508010141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MISSY ALLEN BRADBURN

Provider Business Mailing Address
First Line	:	2010 MIZELL AVE
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792-4119
Country	:	US
Telephone Number	:	813-988-7633
Fax Number	:	813-914-0403

Provider Business Practice Location Address
First Line	:	2010 MIZELL AVENUE
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792
Country	:	US
Telephone Number	:	813-988-7633
Fax Number	:	813-914-0403

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

Provider Enumeration Date	:	11/10/2008
Last Update Date	:	03/29/2012

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