Provider Demographics
NPI:1154840783
Name:MITCHELL, BRADFORD
Entity Type:Individual
Prefix:MR
First Name:BRADFORD
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 643
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-0643
Mailing Address - Country:US
Mailing Address - Phone:510-792-4357
Mailing Address - Fax:510-745-1693
Practice Address - Street 1:6330 THORNTON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560
Practice Address - Country:US
Practice Address - Phone:510-792-4357
Practice Address - Fax:510-745-1693
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)