Provider Demographics
NPI:1851932776
Name:BRADFIELD, LISSI CARYN (BCBA)
Entity Type:Individual
Prefix:MRS
First Name:LISSI
Middle Name:CARYN
Last Name:BRADFIELD
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 NANTUCKET ISLAND CT
Mailing Address - Street 2:
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081-4362
Mailing Address - Country:US
Mailing Address - Phone:904-536-9030
Mailing Address - Fax:
Practice Address - Street 1:8700 ROLLING BROOK LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9024
Practice Address - Country:US
Practice Address - Phone:904-534-6935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-20-46353103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician