Provider Demographics
NPI:1346687613
Name:BRADFORD, EBONY S
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:S
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FOUNDATION
Other - Middle Name:
Other - Last Name:PLUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3204 SHARPVIEW LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75228-6060
Mailing Address - Country:US
Mailing Address - Phone:469-939-7851
Mailing Address - Fax:
Practice Address - Street 1:3204 SHARPVIEW LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-6060
Practice Address - Country:US
Practice Address - Phone:469-939-7851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23424503171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor