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NPI Code Detail

MEDICARE: LEAH DEVAE BRADSHAW

MEDICARE: LEAH DEVAE BRADSHAW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician
21041C0700XClinical Social WorkerP018030NC

General Provider Information

NPI Number : 1043843725
Entity Type Code : Individual
Provider Name (Legal Business Name) : LEAH DEVAE BRADSHAW
Provider Business Mailing Address
First Line : 250 EXECUTIVE PARK BLVD STE 120
Second Line :
City : WINSTON SALEM
State : NC
Zip : 27103-1534
Country : US
Telephone Number : 336-577-0966
Fax Number : 336-962-6739
Provider Business Practice Location Address
First Line : 3000 LATROBE DR STE B
Second Line :
City : CHARLOTTE
State : NC
Zip : 28211-5227
Country : US
Telephone Number : 704-780-4271
Fax Number : 888-261-6694
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/20/2020
Last Update Date : 08/17/2023

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Directions to “ LEAH DEVAE BRADSHAW ” Practice Location

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