Basic Information
| Provider Information | |||||||||
| NPI: | 1689984866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADFORD | ||||||||
| FirstName: | KYMBERLY | ||||||||
| MiddleName: | YVETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5093 | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712115093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186691061 | ||||||||
| FaxNumber: | 3183255385 | ||||||||
| Practice Location | |||||||||
| Address1: | 4951 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712036156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183407535 | ||||||||
| FaxNumber: | 3183401539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2010 | ||||||||
| LastUpdateDate: | 01/08/2018 | ||||||||
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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 | 232194 | NC | N | Behavioral Health & Social Service Providers | Counselor | 101YP2500X | 3686 | LA | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.