Provider Demographics
NPI:1144395815
Name:BRADSHAW, JOHN E
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S ELLSWORTH AVE
Mailing Address - Street 2:#802
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401
Mailing Address - Country:US
Mailing Address - Phone:650-343-6955
Mailing Address - Fax:650-343-6981
Practice Address - Street 1:100 S ELLSWORTH AVE
Practice Address - Street 2:#802
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401
Practice Address - Country:US
Practice Address - Phone:650-343-6955
Practice Address - Fax:650-343-6981
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY79550103T00000X
CAMFC13763106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPK0079550Medicare ID - Type Unspecified