Provider Demographics
NPI:1235746579
Name:BRADFORD, KESHA L (MSW, LGSW)
Entity Type:Individual
Prefix:
First Name:KESHA
Middle Name:L
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4315 IRVING AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55412-1258
Mailing Address - Country:US
Mailing Address - Phone:612-703-2618
Mailing Address - Fax:
Practice Address - Street 1:4315 IRVING AVE N
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55412-1258
Practice Address - Country:US
Practice Address - Phone:612-703-2618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29289101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1780014522Medicaid