Provider Demographics
NPI:1851579585
Name:BRADFORD, WILLIAM DALE (MA,LISAC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DALE
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:MA,LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 WEST SEEDFARM ROAD
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247-0038
Mailing Address - Country:US
Mailing Address - Phone:602-528-3321
Mailing Address - Fax:602-528-1374
Practice Address - Street 1:483 WEST SEEDFARM ROAD
Practice Address - Street 2:
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247-0038
Practice Address - Country:US
Practice Address - Phone:602-528-3321
Practice Address - Fax:602-528-1374
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC-10982101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ346214Medicaid