MEDICARE: DR. MITCHELL JONATHAN BRADBURY PH.D., PSYCHOLOGY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	010694	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	74562	OTHER	NY	UHCUBH PROVIDER ID
2	P1107568	OTHER	NY	OXFORD PROVIDER ID
3	1048319	OTHER	NY	CIGNA
4	5629606	OTHER	NY	AETNA PROVIDER ID
5	V90141	OTHER	NY	EBCBSNY PROVIDER ID

General Provider Information

NPI Number	:	1154486843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MITCHELL JONATHAN BRADBURY PH.D., PSYCHOLOGY

Provider Business Mailing Address
First Line	:	14 HARWOOD CT STE 213
Second Line	:
City	:	SCARSDALE
State	:	NY
Zip	:	10583-4120
Country	:	US
Telephone Number	:	917-751-1868
Fax Number	:

Provider Business Practice Location Address
First Line	:	14 HARWOOD CT STE 213
Second Line	:
City	:	SCARSDALE
State	:	NY
Zip	:	10583-4120
Country	:	US
Telephone Number	:	917-751-1868
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/25/2006
Last Update Date	:	12/28/2022

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