Basic Information
| Provider Information | |||||||||
| NPI: | 1740716489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADSHAW | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2730 S VAL VISTA DR | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852951675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804718560 | ||||||||
| FaxNumber: | 8889798197 | ||||||||
| Practice Location | |||||||||
| Address1: | 2730 S VAL VISTA DR | ||||||||
| Address2: | |||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852951675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804718560 | ||||||||
| FaxNumber: | 8889798197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2017 | ||||||||
| LastUpdateDate: | 05/01/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | LCSW-14027 | AZ | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.