Provider Demographics
NPI:1053483016
Name:BRADSHAW, MICHELLE JENE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JENE
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6027 ARMOR DR
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-6244
Mailing Address - Country:US
Mailing Address - Phone:770-422-2512
Mailing Address - Fax:770-434-3999
Practice Address - Street 1:116 FORREST AVE
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-3640
Practice Address - Country:US
Practice Address - Phone:770-382-3206
Practice Address - Fax:770-382-3276
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT002590225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52171843 001OtherBLUE CROSS BLUE SHIELD
GA10035964OtherAMERIGROUP
GA52171843 003OtherBLUE CROSS BLUE SHIELD
GA312667OtherWELLCARE
GA52171843 002OtherBLUE CROSS BLUE SHIELD