Provider Demographics
NPI:1013670744
Name:BRADFORD, TINZLEY JUANITA (WELLNESS COACH)
Entity Type:Individual
Prefix:
First Name:TINZLEY
Middle Name:JUANITA
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:WELLNESS COACH
Other - Prefix:
Other - First Name:TINZLEY
Other - Middle Name:JUANITA
Other - Last Name:BRADFORD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:WELLNESS COACH
Mailing Address - Street 1:2115 PIEDMONT RD NE APT 4108
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-4181
Mailing Address - Country:US
Mailing Address - Phone:770-572-4239
Mailing Address - Fax:
Practice Address - Street 1:1040 W MARIETTA ST NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-5218
Practice Address - Country:US
Practice Address - Phone:770-572-4239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-19
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052362191101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA052362191OtherDRIVERS LICENSE