Healthcare Provider Details

I. General information

NPI: 1316361082
Provider Name (Legal Business Name): BRADLEY BUZZELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2014
Last Update Date: 02/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 PARK AVE
MIAMISBURG OH
45342-2854
US

IV. Provider business mailing address

540 PARK AVE
MIAMISBURG OH
45342-2854
US

V. Phone/Fax

Practice location:
  • Phone: 937-866-4347
  • Fax: 937-865-5250
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: