Provider Demographics
NPI:1770686693
Name:BRADLEY, TAMARA T (LCSW)
Entity Type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:T
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:485 GARDNER DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-3928
Mailing Address - Country:US
Mailing Address - Phone:208-529-4300
Mailing Address - Fax:208-529-1627
Practice Address - Street 1:1675 CURLEW DRIVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83406
Practice Address - Country:US
Practice Address - Phone:208-529-4300
Practice Address - Fax:208-529-1627
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW-14591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDL5089OtherBLUE CROSS OF IDAHO
ID000010141602OtherREGENCE BLUE SHIELD