Provider Demographics
NPI:1497127427
Name:BRADSTREET, KIRONISHA
Entity Type:Individual
Prefix:MS
First Name:KIRONISHA
Middle Name:
Last Name:BRADSTREET
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 1:1343 ESTATE CIR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-5967
Mailing Address - Country:US
Mailing Address - Phone:985-415-0219
Mailing Address - Fax:985-956-7824
Practice Address - Street 1:208 E THOMAS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-3316
Practice Address - Country:US
Practice Address - Phone:985-956-7823
Practice Address - Fax:985-956-7824
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health