=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336642032
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRADFORD WHITE, PHD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2018
-----------------------------------------------------
Last Update Date | 01/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 E BROADWAY ST STE 7
-----------------------------------------------------
City | PROSPER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75078-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-242-2723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 E BROADWAY ST STE 7
-----------------------------------------------------
City | PROSPER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75078-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 424-242-2723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRADFORD WHITE
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 424-242-2723
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 37415
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------