Healthcare Provider Details

I. General information

NPI: 1942470133
Provider Name (Legal Business Name): G. KENNETH BRADFORD III PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 03/27/2008
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: 510-530-7500
Mailing address:
  • Phone: 925-283-9377
  • Fax: 510-530-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY12277
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: