Provider Demographics
NPI:1114499258
Name:BRADSHAW, MELONIE (PEER SUPPORT)
Entity Type:Individual
Prefix:
First Name:MELONIE
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:PEER SUPPORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1085 S BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:SAINT GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-5245
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1085 S BLUFF ST
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-5245
Practice Address - Country:US
Practice Address - Phone:801-465-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-31
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1035175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist