Provider Demographics
NPI:1801222674
Name:BRADSHAW, MARK BROWNING
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:BROWNING
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CROSBY ROAD
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:MA
Mailing Address - Zip Code:01519
Mailing Address - Country:US
Mailing Address - Phone:508-847-0547
Mailing Address - Fax:
Practice Address - Street 1:3 CROSBY ROAD
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:MA
Practice Address - Zip Code:01519
Practice Address - Country:US
Practice Address - Phone:508-847-0547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA104100000X104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker