Provider Demographics
NPI:1356307086
Name:BRADSHAW, THERESA T (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:T
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:T
Other - Last Name:ERDKAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW LCSW
Mailing Address - Street 1:211 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:CO
Mailing Address - Zip Code:80751
Mailing Address - Country:US
Mailing Address - Phone:970-522-4549
Mailing Address - Fax:970-522-9544
Practice Address - Street 1:910 EAST RAILROAD
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701
Practice Address - Country:US
Practice Address - Phone:970-867-4924
Practice Address - Fax:970-867-2695
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW3371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO802363Medicare ID - Type Unspecified