Provider Demographics
NPI:1164541223
Name:BRADFORD, TARA RENEE (LISW-S)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:RENEE
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:RENEE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 WEST LONG STREET
Mailing Address - Street 2:SOUTHEAST, INC. - FORENSIC TEAM
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215
Mailing Address - Country:US
Mailing Address - Phone:614-600-0300
Mailing Address - Fax:614-225-0988
Practice Address - Street 1:16 WEST LONG STREET
Practice Address - Street 2:SOUTHEAST, INC. - FORENSIC TEAM
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215
Practice Address - Country:US
Practice Address - Phone:614-600-0300
Practice Address - Fax:614-225-0988
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.05004861041C0700X
OHI.0900067-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH08258Medicare UPIN