Healthcare Provider Details

I. General information

NPI: 1871244244
Provider Name (Legal Business Name): BRADLEY THOMAS WILSON LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 QUAIL ST STE 112
NEWPORT BEACH CA
92660-2747
US

IV. Provider business mailing address

1451 QUAIL ST STE 112
NEWPORT BEACH CA
92660-2747
US

V. Phone/Fax

Practice location:
  • Phone: 949-398-8350
  • Fax:
Mailing address:
  • Phone: 714-253-4537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number130605
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number130605
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: