Provider Demographics
NPI:1326540709
Name:BRADFORD, SIMONE
Entity Type:Individual
Prefix:
First Name:SIMONE
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 1:15700 W 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5311 HURON HILLS DR
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-1292
Practice Address - Country:US
Practice Address - Phone:249-842-5142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801085135OtherLICENSE