Provider Demographics
NPI:1376760926
Name:WHITE, BRADLEY H (PHD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:H
Last Name:WHITE
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 1:1010 N COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3309
Mailing Address - Country:US
Mailing Address - Phone:480-461-2409
Mailing Address - Fax:
Practice Address - Street 1:2940 E BANNER GATEWAY DR
Practice Address - Street 2:SUITE 420
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2168
Practice Address - Country:US
Practice Address - Phone:480-543-2688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3604103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z120241Medicare PIN