Provider Demographics
NPI:1619212941
Name:BRADFORD, LAUREN SISK (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:SISK
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 OCONNELL RD
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-1727
Mailing Address - Country:US
Mailing Address - Phone:860-575-1567
Mailing Address - Fax:
Practice Address - Street 1:11 CENTRE ST
Practice Address - Street 2:SUITE 7
Practice Address - City:SALEM
Practice Address - State:CT
Practice Address - Zip Code:06420-3844
Practice Address - Country:US
Practice Address - Phone:860-949-2561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2014-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001152224Z00000X
CT4259225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant