Provider Demographics
NPI:1124218177
Name:BRADFORD, ANITRA LYNETTE (LAC)
Entity Type:Individual
Prefix:MS
First Name:ANITRA
Middle Name:LYNETTE
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 ALDERSGATE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6676
Mailing Address - Country:US
Mailing Address - Phone:501-661-0720
Mailing Address - Fax:
Practice Address - Street 1:621 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-3120
Practice Address - Country:US
Practice Address - Phone:870-234-0739
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0710078101YM0800X
ARP1012084101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health