MEDICARE: DR. ELIZABETH G BRADLEY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0400X	Addiction (Substance Use Disorder) Psychologist	022131	NY
2	103TB0200X	Cognitive & Behavioral Psychologist	022131	NY
3	103TC0700X	Clinical Psychologist	022131	NY
4	103TC1900X	Counseling Psychologist	022131	NY
5	103TC2200X	Clinical Child & Adolescent Psychologist	022131	NY
6	103TF0000X	Family Psychologist	022131	NY
7	103TH0004X	Health Psychologist	022131	NY
8	103TH0100X	Health Service Psychologist	022131	NY
9	103TS0200X	School Psychologist	022131	NY
10	103T00000X	Psychologist	022131	NY

General Provider Information

NPI Number	:	1023530532
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH G BRADLEY PH.D.

Provider Business Mailing Address
First Line	:	959 WASHINGTON AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12206-1415
Country	:	US
Telephone Number	:	518-618-2387
Fax Number	:

Provider Business Practice Location Address
First Line	:	959 WASHINGTON AVE
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12206-1415
Country	:	US
Telephone Number	:	518-618-2387
Fax Number	:	518-813-9291

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2017
Last Update Date	:	03/28/2019

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