Provider Demographics
NPI:1417007311
Name:BRADFORD, LISA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 BANBURY DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9539
Mailing Address - Country:US
Mailing Address - Phone:801-825-1467
Mailing Address - Fax:
Practice Address - Street 1:1466 N HIGHWAY 89
Practice Address - Street 2:SUITE 220
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2738
Practice Address - Country:US
Practice Address - Phone:801-451-0475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13953035011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical