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General NPI Number Information
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NPI Number | 1295120491
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Entity Type | Individual
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Provider Name | ELISE BALDWIN BRADLEY PH.D.
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Gender | Female
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Dates
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Enumeration Date | 04/03/2015
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Last Update Date | 03/12/2021
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Provider Practice Location Address
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Address Line | 12526 HIGH BLUFF DRIVE SUITE SUITE 300
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City | SAN DIEGO
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State | CA
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Zip | 92130
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Country | US
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Telephone | 858-314-8335
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Fax | 855-706-2056
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Provider Business Mailing Address
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Address Line | 4653 CARMEL MOUNTAIN RD SUITE 308 #232
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City | SAN DIEGO
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State | CA
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Zip | 92130
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Country | US
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Telephone | 858-314-8335
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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 | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | P0000003132
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License Number State | TN
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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 | 32335
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | P0000003132
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License Number State | TN
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Taxonomy #4
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Taxonomy Code | 103G00000X
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Taxonomy Name | Clinical Neuropsychologist
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License Number | 32335
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License Number State | CA
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