Healthcare Provider Details

I. General information

NPI: 1538772017
Provider Name (Legal Business Name): LAURA BRADSHAW MS/CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA WRIGHT MS/CCC-SLP

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 08/25/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 LATITUDE LN STE 103
LAKE WYLIE SC
29710-8152
US

IV. Provider business mailing address

512 RED WOLF LN
CLOVER SC
29710-6728
US

V. Phone/Fax

Practice location:
  • Phone: 803-818-0218
  • Fax:
Mailing address:
  • Phone: 724-664-6945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number6812
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: