Healthcare Provider Details

I. General information

NPI: 1437381720
Provider Name (Legal Business Name): BRADLEY JAMES MCCONNELL PSYD, ABPP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 10/11/2021
Certification Date: 09/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 W DIMOND BLVD UNIT 302
ANCHORAGE AK
99502-1555
US

IV. Provider business mailing address

3550 W DIMOND BLVD UNIT 302
ANCHORAGE AK
99502-1555
US

V. Phone/Fax

Practice location:
  • Phone: 661-805-7908
  • Fax: 888-974-1145
Mailing address:
  • Phone: 661-805-7908
  • Fax: 888-974-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number144849
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY60340131
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY26922
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810004895
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: