Healthcare Provider Details

I. General information

NPI: 1023530532
Provider Name (Legal Business Name): ELIZABETH G BRADLEY PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 WASHINGTON AVE
ALBANY NY
12206-1415
US

IV. Provider business mailing address

959 WASHINGTON AVE
ALBANY NY
12206-1415
US

V. Phone/Fax

Practice location:
  • Phone: 518-618-2387
  • Fax: 518-813-9291
Mailing address:
  • Phone: 518-618-2387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number022131
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number022131
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number022131
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number022131
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number022131
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number022131
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number022131
License Number StateNY
# 8
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number022131
License Number StateNY
# 9
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number022131
License Number StateNY
# 10
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number022131
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: