Provider Demographics
NPI:1841767795
Name:ROSE A BRADSHAW, LCSW, PA
Entity Type:Organization
Organization Name:ROSE A BRADSHAW, LCSW, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:207-671-0305
Mailing Address - Street 1:137 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3710
Mailing Address - Country:US
Mailing Address - Phone:207-671-0305
Mailing Address - Fax:207-669-4837
Practice Address - Street 1:40 FOREST FALLS DR STE 3
Practice Address - Street 2:
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096-6905
Practice Address - Country:US
Practice Address - Phone:207-671-0305
Practice Address - Fax:207-669-4837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1437239910Medicaid