MEDICARE: SHAUNA S BRADLEY

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
1	1041C0700X	Clinical Social Worker	121919-3501	UT

General Provider Information

NPI Number	:	1992736656
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAUNA S BRADLEY

Provider Business Mailing Address
First Line	:	PO BOX 681151
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84068-1151
Country	:	US
Telephone Number	:	435-645-7097
Fax Number	:	435-783-4243

Provider Business Practice Location Address
First Line	:	2078 PROSPECTOR AVE
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84060-7321
Country	:	US
Telephone Number	:	435-645-7097
Fax Number	:	435-783-4243

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2006
Last Update Date	:	07/08/2007

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