Basic Information
| Provider Information | |||||||||
| NPI: | 1487999611 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADSHAW | ||||||||
| FirstName: | BROOKE | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | S.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1630 E 2450 S | ||||||||
| Address2: | 31 | ||||||||
| City: | SAINT GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847906228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356325791 | ||||||||
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| Practice Location | |||||||||
| Address1: | 474 W 200 N | ||||||||
| Address2: | |||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847704505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356345660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2012 | ||||||||
| LastUpdateDate: | 11/28/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6111186-3503 | UT | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.