Provider Demographics
NPI:1558494674
Name:BRADFORD, THEODORE (LICSW)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 LEE ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3225
Mailing Address - Country:US
Mailing Address - Phone:617-504-0435
Mailing Address - Fax:
Practice Address - Street 1:1368 BEACON ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-2872
Practice Address - Country:US
Practice Address - Phone:617-504-0435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1105841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07761OtherBCBS PROVIDER NUMBER
MAP07761OtherBCBS PROVIDER NUMBER