Healthcare Provider Details

I. General information

NPI: 1992053169
Provider Name (Legal Business Name): BRADSHAW PSYCHOLGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2012
Last Update Date: 08/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 SOUTHCROSS DR W
BURNSVILLE MN
55306-7012
US

IV. Provider business mailing address

7637 15TH ST N
OAKDALE MN
55128-5600
US

V. Phone/Fax

Practice location:
  • Phone: 952-892-7690
  • Fax: 952-898-4930
Mailing address:
  • Phone: 952-892-7690
  • Fax: 952-898-4930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NANCY L BRADSHAW
Title or Position: 1ST GOV
Credential: RN CNP
Phone: 952-892-7690