Provider Demographics
NPI:1710187539
Name:BRADSHAW, DANIELLE MCGOVERN (DO)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MCGOVERN
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 NORTHEAST DR
Mailing Address - Street 2:MHM SERVICES
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109
Mailing Address - Country:US
Mailing Address - Phone:573-635-3850
Mailing Address - Fax:
Practice Address - Street 1:1101 E HW 54
Practice Address - Street 2:WOMENS EASTERN RECEPTION DIAGNOSTIC AND CORRECTIONAL CE
Practice Address - City:VANDALIA
Practice Address - State:MO
Practice Address - Zip Code:63382
Practice Address - Country:US
Practice Address - Phone:573-594-6686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120128252084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360628Medicare PIN