Healthcare Provider Details

I. General information

NPI: 1487856977
Provider Name (Legal Business Name): BRAD GORDON HAWKINS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 WINROW RD
FORT HUACHUCA AZ
85613-5080
US

IV. Provider business mailing address

2240 WINROW RD
FORT HUACHUCA AZ
85613-5080
US

V. Phone/Fax

Practice location:
  • Phone: 520-533-5161
  • Fax: 520-533-5246
Mailing address:
  • Phone: 520-533-5161
  • Fax: 520-533-5246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number94-266379-2501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3226
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1483
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2025
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: