Provider Demographics
NPI:1013172394
Name:(SMITH) BRADSHAW, STEPHANIE JENE' (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:JENE'
Last Name:(SMITH) BRADSHAW
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 ANGEL LEA
Mailing Address - Street 2:
Mailing Address - City:CARL JUNCTION
Mailing Address - State:MO
Mailing Address - Zip Code:64834-9329
Mailing Address - Country:US
Mailing Address - Phone:417-649-6383
Mailing Address - Fax:
Practice Address - Street 1:1102 W 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3503
Practice Address - Country:US
Practice Address - Phone:417-347-6616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008017253235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist