Provider Demographics
NPI:1073742581
Name:BRADFORD, TALYA DAWN (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:TALYA
Middle Name:DAWN
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:MISS
Other - First Name:TALYA
Other - Middle Name:DAWN
Other - Last Name:BELCHATOVSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:111 HORIZON DR
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1758
Mailing Address - Country:US
Mailing Address - Phone:443-871-8815
Mailing Address - Fax:
Practice Address - Street 1:9881 BROKENLAND PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1172
Practice Address - Country:US
Practice Address - Phone:443-871-8815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC3182101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD654699Medicaid
MD0385921 00Medicaid