Provider Demographics
NPI:1093090359
Name:BRADFORD, ELYSE WISEMAN (BCBA)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:WISEMAN
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RENAISSANCE CTR
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48243-1502
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:772-675-9100
Practice Address - Street 1:400 RENAISSANCE CTR
Practice Address - Street 2:SUITE 2600
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48243-1502
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014952103K00000X
MI1118442103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst