Provider Demographics
NPI:1396043857
Name:BRADFORD, IRENE LOUISE
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:LOUISE
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:PO BOX 572070
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84157-2070
Mailing Address - Country:US
Mailing Address - Phone:801-263-7100
Mailing Address - Fax:
Practice Address - Street 1:1020 S MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84101-3194
Practice Address - Country:US
Practice Address - Phone:888-948-4864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-08
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT101Y00000X-COUNSELOR103K00000X
UT9466365-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst