Healthcare Provider Details

I. General information

NPI: 1477489201
Provider Name (Legal Business Name): BRADLEY JAMES WILLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MANNING DR
CHAPEL HILL NC
27514-4220
US

IV. Provider business mailing address

4501 ASHMONT CT
RALEIGH NC
27616-7811
US

V. Phone/Fax

Practice location:
  • Phone: 984-974-1686
  • Fax:
Mailing address:
  • Phone: 317-626-5504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number613
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: