Provider Demographics
NPI:1063023992
Name:BRADFORD, MCKENZIE LYNN
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:LYNN
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 1:857 E 200 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2317
Mailing Address - Country:US
Mailing Address - Phone:801-487-3276
Mailing Address - Fax:
Practice Address - Street 1:857 E 200 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2317
Practice Address - Country:US
Practice Address - Phone:801-487-3276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
UT12267031-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No172V00000XOther Service ProvidersCommunity Health Worker