Provider Demographics
NPI:1306362686
Name:REYNOLDS, BRADLEY WILLIAM (PHD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:WILLIAM
Last Name:REYNOLDS
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 1:21111 WOOD AVE APT 16
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4136
Mailing Address - Country:US
Mailing Address - Phone:714-625-7232
Mailing Address - Fax:
Practice Address - Street 1:1686 BARTON RD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-1488
Practice Address - Country:US
Practice Address - Phone:909-558-5948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32667103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical