Provider Demographics
NPI:1982855078
Name:BRADSHAW, MARIANA ERIKA (PHD)
Entity Type:Individual
Prefix:
First Name:MARIANA
Middle Name:ERIKA
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MARIANNE
Other - Middle Name:ERIKA
Other - Last Name:WITGERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:P O BOX 4439
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77210-4439
Mailing Address - Country:US
Mailing Address - Phone:713-792-2991
Mailing Address - Fax:
Practice Address - Street 1:1515 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4009
Practice Address - Country:US
Practice Address - Phone:713-792-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33675103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198206801Medicaid
TX87731AOtherBCBS
TXP01076074OtherRR MEDICARE
TX8L3931Medicare PIN