Provider Demographics
NPI:1629387766
Name:BRADSHAW, KELSEY MICHAEL (PHD)
Entity type:Individual
Prefix:MR
First Name:KELSEY
Middle Name:MICHAEL
Last Name:BRADSHAW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 DEL DIOS RD APT 93
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92029-2250
Mailing Address - Country:US
Mailing Address - Phone:208-310-9884
Mailing Address - Fax:
Practice Address - Street 1:145 VALLECITOS DE ORO STE 210
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-1459
Practice Address - Country:US
Practice Address - Phone:619-668-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-06
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28095103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical