Provider Demographics
NPI:1619384815
Name:BRADLEY, BRIAN DAVID
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:DAVID
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4217 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6305
Mailing Address - Country:US
Mailing Address - Phone:248-761-9679
Mailing Address - Fax:248-569-9410
Practice Address - Street 1:30200 TELEGRAPH RD
Practice Address - Street 2:SUITE 207
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4502
Practice Address - Country:US
Practice Address - Phone:248-712-1129
Practice Address - Fax:248-569-9410
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-20
Last Update Date:2014-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICC-0C3110345997103TS0200X
MI6301006993103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool