Healthcare Provider Details

I. General information

NPI: 1154339422
Provider Name (Legal Business Name): SUSAN L BRADSHAW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3790 OLD US 41 N STE A
VALDOSTA GA
31602-6865
US

IV. Provider business mailing address

2704 N OAK ST BUILDING B-3
VALDOSTA GA
31602-1744
US

V. Phone/Fax

Practice location:
  • Phone: 229-262-1000
  • Fax:
Mailing address:
  • Phone: 229-257-0100
  • Fax: 229-257-0050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number000865
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: