Provider Demographics
NPI:1508827031
Name:BRADSHAW, ANGELA R (MCD,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:R
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:MCD,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1298 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:PIGGOTT
Mailing Address - State:AR
Mailing Address - Zip Code:72454-3121
Mailing Address - Country:US
Mailing Address - Phone:870-598-3049
Mailing Address - Fax:
Practice Address - Street 1:1298 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:PIGGOTT
Practice Address - State:AR
Practice Address - Zip Code:72454-3121
Practice Address - Country:US
Practice Address - Phone:870-598-3049
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP16322355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W969OtherBLUECROSS BLUE SHIELD