Provider Demographics
NPI:1275711301
Name:BRADFORD, KATHLEEN (LCPC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 FAIRVIEW AVE.
Mailing Address - Street 2:STE. 235
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-0235
Mailing Address - Country:US
Mailing Address - Phone:406-721-5157
Mailing Address - Fax:406-327-1215
Practice Address - Street 1:1515 FAIRVIEW AVE
Practice Address - Street 2:STE. 235
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-0235
Practice Address - Country:US
Practice Address - Phone:406-721-5157
Practice Address - Fax:406-327-1215
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1316101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1316OtherSTATE LICENSE