Provider Demographics
NPI:1629126131
Name:BRADSHAW, MARY E (LPCC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 PRAIRIE CREST DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-1315
Mailing Address - Country:US
Mailing Address - Phone:505-424-9293
Mailing Address - Fax:505-424-9293
Practice Address - Street 1:12 PRAIRIE CREST DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87508-1315
Practice Address - Country:US
Practice Address - Phone:505-424-9293
Practice Address - Fax:505-424-9293
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2385101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional