Provider Demographics
NPI:1205859394
Name:SHAMIS, BRADLEY (PHD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:SHAMIS
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 1:7028 E THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-4049
Mailing Address - Country:US
Mailing Address - Phone:215-752-2287
Mailing Address - Fax:
Practice Address - Street 1:7010 E ACOMA DR STE 101
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-3550
Practice Address - Country:US
Practice Address - Phone:215-752-2287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPSY-005747103T00000X
PAPS005689L103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2347611000Medicare UPIN
PA617794T19Medicare ID - Type Unspecified