Provider Demographics
NPI:1841632163
Name:BRADSHAW, KARLY DEEN (LMP)
Entity type:Individual
Prefix:
First Name:KARLY
Middle Name:DEEN
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6995 LITTLEROCK RD SW
Mailing Address - Street 2:
Mailing Address - City:TUMWATER
Mailing Address - State:WA
Mailing Address - Zip Code:98512-7246
Mailing Address - Country:US
Mailing Address - Phone:360-581-7267
Mailing Address - Fax:
Practice Address - Street 1:6995 LITTLEROCK RD SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-7246
Practice Address - Country:US
Practice Address - Phone:360-581-7267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60276301225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist