Provider Demographics
NPI:1720506769
Name:BRADSHAW, SHANNON MARIE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:896 THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-3717
Mailing Address - Country:US
Mailing Address - Phone:614-508-2019
Mailing Address - Fax:
Practice Address - Street 1:751 NORTHWEST BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:OH
Practice Address - Zip Code:43212-1977
Practice Address - Country:US
Practice Address - Phone:614-783-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)