Provider Demographics
NPI:1891020467
Name:BRADFORD, LONNIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LONNIE
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3812 8TH ST N STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1421
Mailing Address - Country:US
Mailing Address - Phone:513-612-0876
Mailing Address - Fax:
Practice Address - Street 1:3812 8TH ST N STE 200
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1421
Practice Address - Country:US
Practice Address - Phone:513-612-0876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1673103TC0700X
MN6007103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical