Provider Demographics
NPI:1093890782
Name:BRADSHAW, DAVID R (MED, LP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:MED, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14569 GRAND AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-5729
Mailing Address - Country:US
Mailing Address - Phone:952-892-7690
Mailing Address - Fax:952-898-4930
Practice Address - Street 1:14569 GRAND AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55306-5729
Practice Address - Country:US
Practice Address - Phone:952-892-7690
Practice Address - Fax:952-898-4930
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3945103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist