Provider Demographics
NPI:1144511098
Name:BRADFORD, PAMELA
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 N STATE ROAD 7
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5600
Mailing Address - Country:US
Mailing Address - Phone:754-223-3571
Mailing Address - Fax:
Practice Address - Street 1:3500 N STATE ROAD 7
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5600
Practice Address - Country:US
Practice Address - Phone:754-223-3571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL360336900Medicaid