Provider Demographics
NPI:1437740396
Name:BRADSHAW, DEJAH
Entity Type:Individual
Prefix:
First Name:DEJAH
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 NW 187TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-3015
Mailing Address - Country:US
Mailing Address - Phone:786-237-8174
Mailing Address - Fax:
Practice Address - Street 1:5361 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33142-8035
Practice Address - Country:US
Practice Address - Phone:305-637-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB632161957910Medicaid