Healthcare Provider Details

I. General information

NPI: 1083677561
Provider Name (Legal Business Name): JOHN E BRADFORD PSYD, LP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOHN BRADFORD

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 TEMESCAL CANYON RD STE 205
CORONA CA
92883-4624
US

IV. Provider business mailing address

4160 TEMESCAL CANYON RD STE 205
CORONA CA
92883-4624
US

V. Phone/Fax

Practice location:
  • Phone: 858-279-1223
  • Fax:
Mailing address:
  • Phone: 858-279-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: