Provider Demographics
NPI:1205175346
Name:ALEXANDER-BRADFORD, TISHA DAWN
Entity type:Individual
Prefix:MRS
First Name:TISHA
Middle Name:DAWN
Last Name:ALEXANDER-BRADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:TISHA
Other - Middle Name:DAWN
Other - Last Name:ALEXANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9274 FREEDOM RD
Mailing Address - Street 2:APT 736
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-2192
Mailing Address - Country:US
Mailing Address - Phone:918-938-9775
Mailing Address - Fax:918-227-9925
Practice Address - Street 1:11428 E 20TH ST
Practice Address - Street 2:UNIT A
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-6451
Practice Address - Country:US
Practice Address - Phone:918-878-7877
Practice Address - Fax:918-516-0397
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-09
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200287120AMedicaid