Healthcare Provider Details

I. General information

NPI: 1942878426
Provider Name (Legal Business Name): LINCOLN BRADSHAW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6936 S PROMENADE DR STE 103
COTTONWOOD HEIGHTS UT
84121-5699
US

IV. Provider business mailing address

6936 S PROMENADE DR STE 103
COTTONWOOD HEIGHTS UT
84121-5699
US

V. Phone/Fax

Practice location:
  • Phone: 850-938-4121
  • Fax:
Mailing address:
  • Phone: 850-938-4121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13453078-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: