Provider Demographics
NPI:1619757028
Name:BRADSHAW, KELLY LYNN (LCSW-A)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 STANTON RD
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28504-1428
Mailing Address - Country:US
Mailing Address - Phone:252-468-1941
Mailing Address - Fax:
Practice Address - Street 1:2204 STANTON RD
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28504-1428
Practice Address - Country:US
Practice Address - Phone:252-468-1941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0188751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical