Provider Demographics
NPI:1710182506
Name:BRADSHAW, CLINIECE VAUGHT (COTAL)
Entity Type:Individual
Prefix:MRS
First Name:CLINIECE
Middle Name:VAUGHT
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4975 JM CRAIG RD
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:NC
Mailing Address - Zip Code:28630-9295
Mailing Address - Country:US
Mailing Address - Phone:828-728-7595
Mailing Address - Fax:
Practice Address - Street 1:4975 JM CRAIG RD
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:NC
Practice Address - Zip Code:28630-9295
Practice Address - Country:US
Practice Address - Phone:828-728-7595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1532224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant