MEDICARE: PETER M. BRADLEE PH.D.

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	103T00000X	Psychologist	PSY14507	CA

General Provider Information

NPI Number	:	1477589786
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER M. BRADLEE PH.D.

Provider Business Mailing Address
First Line	:	301 ALAMO DR
Second Line	:	SUITE A-1
City	:	VACAVILLE
State	:	CA
Zip	:	95688-4246
Country	:	US
Telephone Number	:	707-455-8541
Fax Number	:	707-455-7435

Provider Business Practice Location Address
First Line	:	301 ALAMO DR
Second Line	:	SUITE A-1
City	:	VACAVILLE
State	:	CA
Zip	:	95688-4246
Country	:	US
Telephone Number	:	707-455-8541
Fax Number	:	707-455-7435

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

Provider Enumeration Date	:	06/26/2006
Last Update Date	:	07/08/2007

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