Provider Demographics
NPI:1174270052
Name:WEBB-BRADLEY, TRAICE (PHD)
Entity Type:Individual
Prefix:DR
First Name:TRAICE
Middle Name:
Last Name:WEBB-BRADLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BOYLSTON ST FL 16
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02199-1900
Mailing Address - Country:US
Mailing Address - Phone:314-312-2110
Mailing Address - Fax:
Practice Address - Street 1:11000 OPTUM CIR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-2503
Practice Address - Country:US
Practice Address - Phone:877-801-3507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008110103TC0700X
IL1174270052103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical