Provider Demographics
NPI:1740347608
Name:BRADLEY, BRIAN WILLIAM (PHD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WILLIAM
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 1:101 FALLS RD
Mailing Address - Street 2:SUITE 404
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-2612
Mailing Address - Country:US
Mailing Address - Phone:262-375-8441
Mailing Address - Fax:262-546-0005
Practice Address - Street 1:101 FALLS RD
Practice Address - Street 2:SUITE 404
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-2612
Practice Address - Country:US
Practice Address - Phone:262-375-8441
Practice Address - Fax:262-546-0005
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI868103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI868OtherPSYCHOLOGY LICENSE NUMBER
WI39050200Medicaid