Healthcare Provider Details

I. General information

NPI: 1740725944
Provider Name (Legal Business Name): COURTNEY BRADSHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2016
Last Update Date: 12/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 PIEDMONT RD NE STE 350
ATLANTA GA
30305-1582
US

IV. Provider business mailing address

3345 CHATHAM RD NW
ATLANTA GA
30305-1141
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-2008
  • Fax:
Mailing address:
  • Phone: 404-769-1538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPC005010
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: