Healthcare Provider Details

I. General information

NPI: 1053376392
Provider Name (Legal Business Name): BRADLEY WILLIAM PATTERSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 W 14TH ST
PUEBLO CO
81003-2722
US

IV. Provider business mailing address

516 W 14TH ST
PUEBLO CO
81003-2722
US

V. Phone/Fax

Practice location:
  • Phone: 719-545-4983
  • Fax:
Mailing address:
  • Phone: 719-545-0822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1375
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: