Healthcare Provider Details

I. General information

NPI: 1629657200
Provider Name (Legal Business Name): BETTYE JOYCE BRADSHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2021
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1182 5TH ST SE
CAIRO GA
39828-3141
US

IV. Provider business mailing address

1182 5TH ST SE
CAIRO GA
39828-3141
US

V. Phone/Fax

Practice location:
  • Phone: 229-377-0852
  • Fax: 833-771-9974
Mailing address:
  • Phone: 229-377-0852
  • Fax: 833-771-9974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW3466
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004905
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: