=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831669316
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLEE A BRADSHAW MS, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2018
-----------------------------------------------------
Last Update Date | 11/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 E ALDINE ST
-----------------------------------------------------
City | IOWA PARK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76367-1715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-676-9048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 E ALDINE ST
-----------------------------------------------------
City | IOWA PARK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76367-1715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 71474
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------