Healthcare Provider Details

I. General information

NPI: 1669586574
Provider Name (Legal Business Name): BRADLEY G SMALL PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1644 W COLONIAL PKWY
INVERNESS IL
60067-1207
US

IV. Provider business mailing address

1202 HOWARD CIR
WHEATON IL
60187-3811
US

V. Phone/Fax

Practice location:
  • Phone: 847-776-4500
  • Fax: 847-776-4724
Mailing address:
  • Phone: 630-510-1929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: