MEDICARE: DR. BRENT ALAN 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	106H00000X	Marriage & Family Therapist	35001519A	IN
2	106H00000X	Marriage & Family Therapist	201382	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000388057	OTHER	IN	BCBS
2	835937000	OTHER	IN	MAGELLAN

General Provider Information

NPI Number	:	1972538130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENT ALAN BRADLEY PH.D.

Provider Business Mailing Address
First Line	:	2413 DUHON PL
Second Line	:
City	:	SEABROOK
State	:	TX
Zip	:	77586-3351
Country	:	US
Telephone Number	:	832-425-2495
Fax Number	:

Provider Business Practice Location Address
First Line	:	2515 NASA PKWY
Second Line	:	SUITE B 10
City	:	SEABROOK
State	:	TX
Zip	:	77586-3479
Country	:	US
Telephone Number	:	832-425-2495
Fax Number	:

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	10/28/2011

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