Provider Demographics
NPI:1477522555
Name:SMITH, BRADFORD MARSHALL (PHD)
Entity Type:Individual
Prefix:
First Name:BRADFORD
Middle Name:MARSHALL
Last Name:SMITH
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 1:110 HALE ST
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-4634
Mailing Address - Country:US
Mailing Address - Phone:781-710-8300
Mailing Address - Fax:
Practice Address - Street 1:110 HALE ST
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-4634
Practice Address - Country:US
Practice Address - Phone:781-710-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS54963103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50256Medicare ID - Type Unspecified