Healthcare Provider Details

I. General information

NPI: 1659257327
Provider Name (Legal Business Name): MARY BRADSHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19000 ST JOES PKWY STE 310
LIVONIA MI
48152-1477
US

IV. Provider business mailing address

24 FRANK LLOYD WRIGHT DR STE J2000
ANN ARBOR MI
48105-9484
US

V. Phone/Fax

Practice location:
  • Phone: 734-743-4540
  • Fax:
Mailing address:
  • Phone: 734-747-6766
  • Fax: 734-222-3100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851120429APP25
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: