Provider Demographics
NPI:1053139568
Name:BRADFORD, ERIKA AVIS (SUDPT)
Entity type:Individual
Prefix:
First Name:ERIKA
Middle Name:AVIS
Last Name:BRADFORD
Suffix:
Gender:F
Credentials:SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12620 197TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6066
Mailing Address - Country:US
Mailing Address - Phone:253-455-0815
Mailing Address - Fax:
Practice Address - Street 1:232 2ND AVE S STE 201
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-5862
Practice Address - Country:US
Practice Address - Phone:253-859-0300
Practice Address - Fax:253-859-0745
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61558328390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program