Provider Demographics
NPI:1275041758
Name:BRADFORD, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BRADFORD
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 1:1021 N MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3877
Mailing Address - Country:US
Mailing Address - Phone:815-387-5600
Mailing Address - Fax:815-316-4726
Practice Address - Street 1:1222 E VOORHEES ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61834-6249
Practice Address - Country:US
Practice Address - Phone:217-477-4500
Practice Address - Fax:217-443-6613
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490117861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical