Healthcare Provider Details

I. General information

NPI: 1770885634
Provider Name (Legal Business Name): VANESSA BRADLEY PH. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9854 NATIONAL BLVD # 418
LOS ANGELES CA
90034-2713
US

IV. Provider business mailing address

9854 NATIONAL BLVD # 418
LOS ANGELES CA
90034-2713
US

V. Phone/Fax

Practice location:
  • Phone: 650-817-9070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY18395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: