Provider Demographics
NPI:1053720557
Name:BRADLEY, SHANNON DEIRDRE (LCSW)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DEIRDRE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5502 MARVIN SHIELDS BLVD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501
Mailing Address - Country:US
Mailing Address - Phone:282-822-5710
Mailing Address - Fax:
Practice Address - Street 1:5502 MARVIN SHIELDS BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-822-5710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-08
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 133121041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical