1053944397 NPI number — MRS. ALICIA G BRADSHAW MS, MFTI

Table of content: MRS. ALICIA G BRADSHAW MS, MFTI (NPI 1053944397)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053944397 NPI number — MRS. ALICIA G BRADSHAW MS, MFTI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADSHAW
Provider First Name:
ALICIA
Provider Middle Name:
G
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, MFTI
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GARCIA
Provider Other First Name:
ALICIA
Provider Other Middle Name:
N
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1053944397
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
204 BROOKWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHATTANOOGA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37411-1803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-402-8256
Provider Business Mailing Address Fax Number:
423-541-4148

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7111 LEE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHATTANOOGA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37421-6706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-402-8256
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/14/2020

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:  1511 , 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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