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General NPI Number Information
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NPI Number | 1174270052
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Entity Type | Individual
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Provider Name | TRAICE WEBB-BRADLEY PHD
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Gender | Female
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Dates
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Enumeration Date | 03/09/2022
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Last Update Date | 04/25/2022
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Provider Practice Location Address
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Address Line | 11000 OPTUM CIR
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City | EDEN PRAIRIE
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State | MN
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Zip | 55344-2503
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Country | US
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Telephone | 877-801-3507
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Fax |
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Provider Business Mailing Address
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Address Line | 800 BOYLSTON ST FL 16
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City | BOSTON
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State | MA
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Zip | 02199-1900
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Country | US
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Telephone | 314-312-2110
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071008110
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1174270052
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License Number State | IL
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