Basic Information
| Provider Information | |||||||||
| NPI: | 1396043857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADFORD | ||||||||
| FirstName: | IRENE | ||||||||
| MiddleName: | LOUISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 572070 | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841572070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012637100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1020 S MAIN ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841013194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889484864 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2011 | ||||||||
| LastUpdateDate: | 11/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 101Y00000X-COUNSELOR | UT | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 1041C0700X | 9466365-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.