Provider Demographics
NPI:1083015150
Name:HERRING, BRADFORD
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:
Last Name:HERRING
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 1:101 ECHO GLEN DR APT A1
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-5903
Mailing Address - Country:US
Mailing Address - Phone:910-734-8744
Mailing Address - Fax:
Practice Address - Street 1:100 S MARSHALL ST STE 1
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2843
Practice Address - Country:US
Practice Address - Phone:336-723-4130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-09
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA10986101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3410095Medicaid