Provider Demographics
NPI:1245575406
Name:KEFFER, BRADLEY
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:KEFFER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1868 EL SEGUNDO TRL
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-4032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N SILVER ST
Practice Address - Street 2:
Practice Address - City:T OR C
Practice Address - State:NM
Practice Address - Zip Code:87901-1957
Practice Address - Country:US
Practice Address - Phone:575-894-7855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1582235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist