Provider Demographics
NPI:1053944397
Name:BRADSHAW, ALICIA G (MS, MFTI)
Entity type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:G
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:MS, MFTI
Other - Prefix:MS
Other - First Name:ALICIA
Other - Middle Name:N
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:204 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-1803
Mailing Address - Country:US
Mailing Address - Phone:423-402-8256
Mailing Address - Fax:423-541-4148
Practice Address - Street 1:7111 LEE HWY
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-6706
Practice Address - Country:US
Practice Address - Phone:423-402-8256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1511106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist