Basic Information
| Provider Information | |||||||||
| NPI: | 1588733208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRADSHAW | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 BEASLEY ST | ||||||||
| Address2: | STE 120 | ||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405094266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592541035 | ||||||||
| FaxNumber: | 8592542075 | ||||||||
| Practice Location | |||||||||
| Address1: | 1508 GREENUP AVE | ||||||||
| Address2: | STE 1 | ||||||||
| City: | ASHLAND | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411017614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592541035 | ||||||||
| FaxNumber: | 8592542075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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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 | 163WP0808X | 104911 | KY | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 106H00000X | 104911 | KY | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7100391530 | 05 | KY | MEDICAID | 30615058 | 05 | KY | MEDICAID |