Healthcare Provider Details

I. General information

NPI: 1508896416
Provider Name (Legal Business Name): G. KENNETH BRADFORD, III, PHD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 03/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

936 DEWING AVE STE E
LAFAYETTE CA
94549-4246
US

IV. Provider business mailing address

936 DEWING AVE STE E
LAFAYETTE CA
94549-4246
US

V. Phone/Fax

Practice location:
  • Phone: 925-283-9377
  • Fax:
Mailing address:
  • Phone: 925-283-9377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPSY12277
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY12277
License Number StateCA

VIII. Authorized Official

Name: DR. GEORGE KENNETH BRADFORD III
Title or Position: PSYCHOLOGIST/OWNER
Credential: PHD
Phone: 925-283-9377