Provider Demographics
NPI:1093295032
Name:BRADSHAW, KAITLYN (BCBA)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 W RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-1322
Mailing Address - Country:US
Mailing Address - Phone:605-271-2690
Mailing Address - Fax:
Practice Address - Street 1:745 10TH ST STE C
Practice Address - Street 2:
Practice Address - City:ROCK VALLEY
Practice Address - State:IA
Practice Address - Zip Code:51247-1511
Practice Address - Country:US
Practice Address - Phone:712-454-3484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARBT-18-57026106S00000X
LA1-20-45677103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2455559Medicaid