Provider Demographics
NPI:1841686375
Name:BRADFORD, KAMILAH
Entity type:Individual
Prefix:
First Name:KAMILAH
Middle Name:
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10524 EVANS PLZ APT 717
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-3456
Mailing Address - Country:US
Mailing Address - Phone:402-609-6837
Mailing Address - Fax:
Practice Address - Street 1:6681 SORENSEN PKWY
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68152-2139
Practice Address - Country:US
Practice Address - Phone:402-932-8884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE45-3960708Medicaid