Provider Demographics
NPI:1851592315
Name:BRADLEY, PETER DOUGLAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:DOUGLAS
Last Name:BRADLEY
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 1:2904 CORPORATE CIR
Mailing Address - Street 2:SUITE 129
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-2292
Mailing Address - Country:US
Mailing Address - Phone:469-635-7540
Mailing Address - Fax:
Practice Address - Street 1:2904 CORPORATE CIR
Practice Address - Street 2:SUITE 129
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-2292
Practice Address - Country:US
Practice Address - Phone:469-635-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13501101YP2500X
TX42622106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist