1275563843 NPI number — MRS. KATHLEEN SULLIVAN BRADSHAW LMFT

Table of content: MRS. KATHLEEN SULLIVAN BRADSHAW LMFT (NPI 1275563843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275563843 NPI number — MRS. KATHLEEN SULLIVAN BRADSHAW LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADSHAW
Provider First Name:
KATHLEEN
Provider Middle Name:
SULLIVAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SULLIVAN
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMFT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275563843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2018 WESTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37921-5718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-544-0406
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2018 WESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37921-5718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-544-0406
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/03/2006

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: 106H00000X , with the licence number:  0732 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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