Provider Demographics
NPI:1083157424
Name:BRADSHAW, ELIZABETH MORGAN (CSWA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MORGAN
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:CSWA
Other - Prefix:
Other - First Name:MORGAN
Other - Middle Name:
Other - Last Name:BRADSHAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CSWA
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:12360 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1042
Practice Address - Country:US
Practice Address - Phone:971-278-9480
Practice Address - Fax:971-279-2051
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA12064104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500718609Medicaid