Provider Demographics
NPI:1942470133
Name:BRADFORD, G. KENNETH III (PHD)
Entity Type:Individual
Prefix:DR
First Name:G.
Middle Name:KENNETH
Last Name:BRADFORD
Suffix:III
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 1:936 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:510-530-7500
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:510-530-7500
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-04
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY12277103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PL122770Medicare PIN