MEDICARE: DR. BRIAN WILLIAM BRADLEY 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	103TC0700X	Clinical Psychologist	868	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	868	OTHER	WI	PSYCHOLOGY LICENSE NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1740347608
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN WILLIAM BRADLEY PH.D.

Provider Business Mailing Address
First Line	:	101 FALLS RD
Second Line	:	SUITE 404
City	:	GRAFTON
State	:	WI
Zip	:	53024-2612
Country	:	US
Telephone Number	:	262-375-8441
Fax Number	:	262-546-0005

Provider Business Practice Location Address
First Line	:	101 FALLS RD
Second Line	:	SUITE 404
City	:	GRAFTON
State	:	WI
Zip	:	53024-2612
Country	:	US
Telephone Number	:	262-375-8441
Fax Number	:	262-546-0005

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

Provider Enumeration Date	:	01/02/2007
Last Update Date	:	07/08/2007

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