=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629387766
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSEY MICHAEL BRADSHAW PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2010
-----------------------------------------------------
Last Update Date | 03/24/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 VALLECITOS DE ORO STE 210
-----------------------------------------------------
City | SAN MARCOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92069-1459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-668-6200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 910 DEL DIOS RD APT 93
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92029-2250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-310-9884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY28095
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------