Provider Demographics
NPI:1538772017
Name:BRADSHAW, LAURA (MS/CCC-SLP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS/CCC-SLP
Mailing Address - Street 1:512 RED WOLF LN
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-6728
Mailing Address - Country:US
Mailing Address - Phone:724-664-6945
Mailing Address - Fax:
Practice Address - Street 1:252 LATITUDE LN STE 103
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-8152
Practice Address - Country:US
Practice Address - Phone:803-818-0218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6812208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5559Medicaid