Provider Demographics
NPI:1194032862
Name:BRADFORD, REED EVAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:REED
Middle Name:EVAN
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BRIDGEPOINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7001
Mailing Address - Country:US
Mailing Address - Phone:601-201-8397
Mailing Address - Fax:
Practice Address - Street 1:103 BRIDGEPOINTE BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-7001
Practice Address - Country:US
Practice Address - Phone:601-201-8397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-01
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS33-541103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I688432Medicare PIN