Provider Demographics
NPI:1770341166
Name:BRADFORD, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17812 BATESVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-1714
Mailing Address - Country:US
Mailing Address - Phone:870-278-8814
Mailing Address - Fax:
Practice Address - Street 1:17812 BATESVILLE PIKE
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-1714
Practice Address - Country:US
Practice Address - Phone:870-278-8814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool