Healthcare Provider Details

I. General information

NPI: 1619384815
Provider Name (Legal Business Name): MR. BRIAN DAVID BRADLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2014
Last Update Date: 08/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30200 TELEGRAPH RD SUITE 207
BINGHAM FARMS MI
48025-4502
US

IV. Provider business mailing address

4217 ARLINGTON DR
ROYAL OAK MI
48073-6305
US

V. Phone/Fax

Practice location:
  • Phone: 248-712-1129
  • Fax: 248-569-9410
Mailing address:
  • Phone: 248-761-9679
  • Fax: 248-569-9410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberCC-0C3110345997
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301006993
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: