Provider Demographics
NPI:1255363586
Name:SAMUEL, BRADLEY WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:WILLIAM
Last Name:SAMUEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:2400 TUCKER NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-1734
Practice Address - Fax:505-272-6308
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NM738103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO09702784Medicaid
NMNM01JB06OtherBLUE SHIELD
AZ955627Medicaid
AZ955627Medicaid