Provider Demographics
NPI:1114010451
Name:BRADFORD, MICHAEL-DAVID ROBERT (LPC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL-DAVID
Middle Name:ROBERT
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3045 TRINITY LAKES DR
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-7458
Mailing Address - Country:US
Mailing Address - Phone:817-726-8165
Mailing Address - Fax:
Practice Address - Street 1:3045 TRINITY LAKES DR
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-7458
Practice Address - Country:US
Practice Address - Phone:817-726-8165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20103101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178702001Medicaid