Provider Demographics
NPI:1245847169
Name:BRADBERRY, MEDEA ELIZABETH (LCSW, LSCSW)
Entity type:Individual
Prefix:
First Name:MEDEA
Middle Name:ELIZABETH
Last Name:BRADBERRY
Suffix:
Gender:F
Credentials:LCSW, LSCSW
Other - Prefix:
Other - First Name:MEDEA
Other - Middle Name:ELIZABETH
Other - Last Name:CAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1213 R D MIZE RD APT A
Mailing Address - Street 2:
Mailing Address - City:GRAIN VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64029-9462
Mailing Address - Country:US
Mailing Address - Phone:573-999-2733
Mailing Address - Fax:
Practice Address - Street 1:1213 R D MIZE RD APT A
Practice Address - Street 2:
Practice Address - City:GRAIN VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64029-9462
Practice Address - Country:US
Practice Address - Phone:573-999-2733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS52141041C0700X
MO20190354231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical