Healthcare Provider Details

I. General information

NPI: 1629126131
Provider Name (Legal Business Name): MARY E BRADSHAW LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 PRAIRIE CREST DR
SANTA FE NM
87508-1315
US

IV. Provider business mailing address

12 PRAIRIE CREST DR
SANTA FE NM
87508-1315
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-9293
  • Fax: 505-424-9293
Mailing address:
  • Phone: 505-424-9293
  • Fax: 505-424-9293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2385
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: