Provider Demographics
NPI:1093090821
Name:BRADSHAW, VANESSA LYNN (10940089)
Entity Type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:LYNN
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:10940089
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 W 76TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-1729
Mailing Address - Country:US
Mailing Address - Phone:310-743-6988
Mailing Address - Fax:
Practice Address - Street 1:436 W 76TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-1729
Practice Address - Country:US
Practice Address - Phone:310-743-6988
Practice Address - Fax:323-753-4065
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist