Provider Demographics
NPI:1780937300
Name:BRADSHAW, AMANDA L (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 N SEA PINES
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-3664
Mailing Address - Country:US
Mailing Address - Phone:602-312-5066
Mailing Address - Fax:
Practice Address - Street 1:1730 N SEA PINES
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-3664
Practice Address - Country:US
Practice Address - Phone:602-312-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP7506235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist