1285936260 NPI number — MRS. STALEY BRADBURN JUSTICE LMSW

Table of content: MRS. STALEY BRADBURN JUSTICE LMSW (NPI 1285936260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285936260 NPI number — MRS. STALEY BRADBURN JUSTICE LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUSTICE
Provider First Name:
STALEY
Provider Middle Name:
BRADBURN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285936260
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
521 KRISTI ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROBINSON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76706-5120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 MEMORIAL DR
Provider Second Line Business Practice Location Address:
151W
Provider Business Practice Location Address City Name:
WACO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76711-1329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-297-3951
Provider Business Practice Location Address Fax Number:
254-297-3562
Provider Enumeration Date:
11/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  52624 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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