Provider Demographics
NPI:1588733208
Name:BRADSHAW, MARY K (LMFT)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:K
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
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Mailing Address - Street 1:900 BEASLEY ST
Mailing Address - Street 2:STE 120
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-4266
Mailing Address - Country:US
Mailing Address - Phone:859-254-1035
Mailing Address - Fax:859-254-2075
Practice Address - Street 1:1508 GREENUP AVE
Practice Address - Street 2:STE 1
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7614
Practice Address - Country:US
Practice Address - Phone:859-254-1035
Practice Address - Fax:859-254-2075
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY104911163WP0808X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100391530Medicaid
KY30615058Medicaid