Provider Demographics
NPI:1053138404
Name:BRADSHAW, MIJA (SUDP)
Entity type:Individual
Prefix:
First Name:MIJA
Middle Name:
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:SUDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 8TH AVE SE STE A
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-1122
Mailing Address - Country:US
Mailing Address - Phone:360-923-9585
Mailing Address - Fax:888-310-1691
Practice Address - Street 1:3925 8TH AVE SE STE A
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1122
Practice Address - Country:US
Practice Address - Phone:360-923-9585
Practice Address - Fax:888-310-1691
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00003745101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)