Provider Demographics
NPI:1578508529
Name:BRADFORD, LYNN E (PHD, HSPP)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:E
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-962-4836
Mailing Address - Fax:317-962-8646
Practice Address - Street 1:2620 KESSLER BOULEVARD EAST DR
Practice Address - Street 2:SUITE 210
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2890
Practice Address - Country:US
Practice Address - Phone:317-475-6200
Practice Address - Fax:317-475-6212
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040774103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INS18657Medicare UPIN
IN676300FMedicare PIN