Provider Demographics
NPI:1063003945
Name:DAWSON, BRADFORD
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:
Last Name:DAWSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-1907
Practice Address - Country:US
Practice Address - Phone:217-728-4358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker