Provider Demographics
NPI:1396912986
Name:BRADSHAW, DIANE K (MS)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:K
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 GREAT FOREST RD
Mailing Address - Street 2:
Mailing Address - City:GRIMESLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27837-9049
Mailing Address - Country:US
Mailing Address - Phone:252-916-4613
Mailing Address - Fax:252-328-4868
Practice Address - Street 1:367 GREAT FOREST RD
Practice Address - Street 2:
Practice Address - City:GRIMESLAND
Practice Address - State:NC
Practice Address - Zip Code:27837-9049
Practice Address - Country:US
Practice Address - Phone:252-916-4613
Practice Address - Fax:252-328-4868
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7216101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11767847OtherCAQH