Provider Demographics
NPI:1639802549
Name:BRADFORD, EMILY LOUISE
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:LOUISE
Last Name:BRADFORD
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 1:1640 LAKEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-6122
Mailing Address - Country:US
Mailing Address - Phone:904-200-9688
Mailing Address - Fax:
Practice Address - Street 1:1 VANTAGE WAY STE E130
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37228-1591
Practice Address - Country:US
Practice Address - Phone:615-988-4763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6123101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health