Provider Demographics
NPI:1003820028
Name:BRADLEY, JOHN MACKEMER (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MACKEMER
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:DR
Other - First Name:MAC
Other - Middle Name:
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:1777 S HARRISON ST STE 805
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-3933
Mailing Address - Country:US
Mailing Address - Phone:303-691-1700
Mailing Address - Fax:303-758-5319
Practice Address - Street 1:1777 S HARRISON ST STE 805
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-3933
Practice Address - Country:US
Practice Address - Phone:303-691-1700
Practice Address - Fax:303-758-5319
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2935103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
696710Medicare ID - Type Unspecified