Healthcare Provider Details

I. General information

NPI: 1710187539
Provider Name (Legal Business Name): DANIELLE MCGOVERN BRADSHAW D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E HW 54 WOMENS EASTERN RECEPTION DIAGNOSTIC AND CORRECTIONAL CE
VANDALIA MO
63382
US

IV. Provider business mailing address

1026 NORTHEAST DR MHM SERVICES
JEFFERSON CITY MO
65109
US

V. Phone/Fax

Practice location:
  • Phone: 573-594-6686
  • Fax:
Mailing address:
  • Phone: 573-635-3850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2012012825
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: