Provider Demographics
NPI:1568874030
Name:BRADFORD, TONY
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6706 N 9TH AVE
Mailing Address - Street 2:SUITE B-5
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-9303
Mailing Address - Country:US
Mailing Address - Phone:850-462-4153
Mailing Address - Fax:
Practice Address - Street 1:6706 N 9TH AVE
Practice Address - Street 2:SUITE B-5
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-9303
Practice Address - Country:US
Practice Address - Phone:850-462-4153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW 75331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical