Provider Demographics
NPI:1629613575
Name:BRADFORD, PAUL L (ACSW)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:L
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 CHRISTIANSEN CIR
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95776-5588
Mailing Address - Country:US
Mailing Address - Phone:707-319-4880
Mailing Address - Fax:
Practice Address - Street 1:275 BECK AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6804
Practice Address - Country:US
Practice Address - Phone:707-784-8501
Practice Address - Fax:707-428-6542
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA217453101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW102007OtherASSOCIATE CLINICAL SOCIAL WORKER REG #