Provider Demographics
NPI:1154339422
Name:BRADSHAW, SUSAN L (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 N OAK ST
Mailing Address - Street 2:BUILDING B-3
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1744
Mailing Address - Country:US
Mailing Address - Phone:229-257-0100
Mailing Address - Fax:229-257-0050
Practice Address - Street 1:3790 OLD US 41 N STE A
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-6865
Practice Address - Country:US
Practice Address - Phone:229-262-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000865106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA592486097AMedicaid