Provider Demographics
NPI:1043462377
Name:BRADSHAW, THERESA (BS)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 E CHESTNUT ST
Mailing Address - Street 2:SUITE 510
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-5700
Mailing Address - Country:US
Mailing Address - Phone:502-589-0802
Mailing Address - Fax:502-589-0805
Practice Address - Street 1:401 E CHESTNUT ST
Practice Address - Street 2:SUITE 510
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5700
Practice Address - Country:US
Practice Address - Phone:502-589-0802
Practice Address - Fax:502-589-0805
Is Sole Proprietor?:No
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R2889225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY-R2889OtherLICENSE