1992053169 NPI number — BRADSHAW PSYCHOLGICAL SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992053169 NPI number — BRADSHAW PSYCHOLGICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADSHAW PSYCHOLGICAL SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1992053169
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7637 15TH ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAKDALE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55128-5600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-892-7690
Provider Business Mailing Address Fax Number:
952-898-4930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1751 SOUTHCROSS DR W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURNSVILLE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55306-7012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-892-7690
Provider Business Practice Location Address Fax Number:
952-898-4930
Provider Enumeration Date:
08/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BRADSHAW
Authorized Official First Name:
NANCY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
1ST GOV
Authorized Official Telephone Number:
952-892-7690

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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