Provider Demographics
NPI:1104091198
Name:BRADFORD, KOSSOUTH EDWARD (LCSW)
Entity type:Individual
Prefix:MR
First Name:KOSSOUTH
Middle Name:EDWARD
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 YORK ST STE 2B
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5660
Mailing Address - Country:US
Mailing Address - Phone:203-787-5723
Mailing Address - Fax:
Practice Address - Street 1:123 YORK ST STE 2B
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5660
Practice Address - Country:US
Practice Address - Phone:203-787-5723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0066951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical