Provider Demographics
NPI:1689140188
Name:MAZER, BRADLEY THOMAS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:THOMAS
Last Name:MAZER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 N ARM DR
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-8207
Mailing Address - Country:US
Mailing Address - Phone:612-790-7912
Mailing Address - Fax:
Practice Address - Street 1:4801 E LINWOOD BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64128-2226
Practice Address - Country:US
Practice Address - Phone:816-861-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6314103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist