Provider Demographics
NPI:1235553108
Name:BRADSHAW, CARRIE MARIE (MS/CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:MARIE
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29294 390TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIGGSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62340-2273
Mailing Address - Country:US
Mailing Address - Phone:217-430-3410
Mailing Address - Fax:
Practice Address - Street 1:29294 390TH ST
Practice Address - Street 2:
Practice Address - City:GRIGGSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62340-2273
Practice Address - Country:US
Practice Address - Phone:217-430-3410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146010674235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist