Provider Demographics
NPI:1154486843
Name:BRADBURY, MITCHELL JONATHAN (PHD, PSYCHOLOGY)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:JONATHAN
Last Name:BRADBURY
Suffix:
Gender:M
Credentials:PHD, PSYCHOLOGY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 HARWOOD CT STE 213
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-4120
Mailing Address - Country:US
Mailing Address - Phone:917-751-1868
Mailing Address - Fax:
Practice Address - Street 1:14 HARWOOD CT STE 213
Practice Address - Street 2:
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-4120
Practice Address - Country:US
Practice Address - Phone:917-751-1868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-25
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010694103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY74562OtherUHCUBH PROVIDER ID
NYP1107568OtherOXFORD PROVIDER ID
NY1048319OtherCIGNA
NY5629606OtherAETNA PROVIDER ID
NYV90141OtherEBCBSNY PROVIDER ID
NYV90141OtherEBCBSNY PROVIDER ID
NY01763428Medicaid
NY5629606OtherAETNA PROVIDER ID
NY01763428Medicaid