Basic Information
| Provider Information | |||||||||
| NPI: | 1669643045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADFORD | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | MARTIN | ||||||||
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| Credential: | RRW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 907 W LANCASTER BLVD | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935342305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617262630 | ||||||||
| FaxNumber: | 6619518820 | ||||||||
| Practice Location | |||||||||
| Address1: | 907 W LANCASTER BLVD | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935342305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6617262630 | ||||||||
| FaxNumber: | 6619518820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 03/13/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | RW0234 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.