Basic Information
| Provider Information | |||||||||
| NPI: | 1205175346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALEXANDER-BRADFORD | ||||||||
| FirstName: | TISHA | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | ALEXANDER | ||||||||
| OtherFirstName: | TISHA | ||||||||
| OtherMiddleName: | DAWN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9274 FREEDOM RD | ||||||||
| Address2: | APT 736 | ||||||||
| City: | SAPULPA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740662192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189389775 | ||||||||
| FaxNumber: | 9182279925 | ||||||||
| Practice Location | |||||||||
| Address1: | 11428 E 20TH ST | ||||||||
| Address2: | UNIT A | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741286451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188787877 | ||||||||
| FaxNumber: | 9185160397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2013 | ||||||||
| LastUpdateDate: | 02/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 200287120A | 05 | OK | MEDICAID |