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NPI Code Detail

MEDICARE: MR. BRIAN DAVID BRADLEY

MEDICARE: MR. BRIAN DAVID BRADLEY
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
1103TS0200XSchool PsychologistCC-0C3110345997MI
2103TC0700XClinical Psychologist6301006993MI

General Provider Information

NPI Number : 1619384815
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BRIAN DAVID BRADLEY
Provider Business Mailing Address
First Line : 4217 ARLINGTON DR
Second Line :
City : ROYAL OAK
State : MI
Zip : 48073-6305
Country : US
Telephone Number : 248-761-9679
Fax Number : 248-569-9410
Provider Business Practice Location Address
First Line : 30200 TELEGRAPH RD
Second Line : SUITE 207
City : BINGHAM FARMS
State : MI
Zip : 48025-4502
Country : US
Telephone Number : 248-712-1129
Fax Number : 248-569-9410
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/20/2014
Last Update Date : 08/09/2014

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