Provider Demographics
NPI:1508896416
Name:G. KENNETH BRADFORD, III, PHD
Entity Type:Organization
Organization Name:G. KENNETH BRADFORD, III, PHD
Other - Org Name:DIABLO VALLEY PSYCHOTHERAPY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:III
Authorized Official - Credentials:PHD
Authorized Official - Phone:925-283-9377
Mailing Address - Street 1:936 DEWING AVE STE E
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-4246
Mailing Address - Country:US
Mailing Address - Phone:925-283-9377
Mailing Address - Fax:
Practice Address - Street 1:936 DEWING AVE STE E
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-4246
Practice Address - Country:US
Practice Address - Phone:925-283-9377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12277103T00000X, 103TA0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & AgingGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL122770Medicare ID - Type Unspecified