Provider Demographics
NPI:1407330319
Name:BRADSHAW, MAMIE ARNETTA (CDCA)
Entity type:Individual
Prefix:
First Name:MAMIE
Middle Name:ARNETTA
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 GRAND AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45205-2259
Mailing Address - Country:US
Mailing Address - Phone:513-307-3501
Mailing Address - Fax:
Practice Address - Street 1:3131 HARVEY AVE STE 104
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3006
Practice Address - Country:US
Practice Address - Phone:513-585-8274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.161803101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)