Provider Demographics
NPI:1134674823
Name:BRADBURY, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BRADBURY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 MAGNOLIA LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-7543
Mailing Address - Country:US
Mailing Address - Phone:630-420-6341
Mailing Address - Fax:
Practice Address - Street 1:1024 MAGNOLIA LN
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-7543
Practice Address - Country:US
Practice Address - Phone:630-420-6341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490057251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical