Provider Demographics
NPI:1790288934
Name:BRADSHAW, SPENCER D (LMFTA, PHD)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:D
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:LMFTA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 LONGHORN BLVD
Mailing Address - Street 2:
Mailing Address - City:WOLFFORTH
Mailing Address - State:TX
Mailing Address - Zip Code:79382-5315
Mailing Address - Country:US
Mailing Address - Phone:801-450-6936
Mailing Address - Fax:
Practice Address - Street 1:8200 NASHVILLE AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1906
Practice Address - Country:US
Practice Address - Phone:801-450-6936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201891106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist