Provider Demographics
NPI:1922729672
Name:BRADFORD, MAGAN NICOLE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MAGAN
Middle Name:NICOLE
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2186 COUNTY ROAD 2425
Mailing Address - Street 2:
Mailing Address - City:COMO
Mailing Address - State:TX
Mailing Address - Zip Code:75431-4800
Mailing Address - Country:US
Mailing Address - Phone:903-348-8908
Mailing Address - Fax:
Practice Address - Street 1:13017 E TEXAS HIGHWAY 11
Practice Address - Street 2:
Practice Address - City:COMO
Practice Address - State:TX
Practice Address - Zip Code:75431-3716
Practice Address - Country:US
Practice Address - Phone:903-488-3671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110333235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty