Provider Demographics
NPI:1629795034
Name:BRADSHAW, TAYLOR DIANE
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:DIANE
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 1:9245 LAGUNA SPRINGS DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7991
Mailing Address - Country:US
Mailing Address - Phone:916-632-1330
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:9245 LAGUNA SPRINGS DR STE 2OO
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7987
Practice Address - Country:US
Practice Address - Phone:916-632-1330
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician