Provider Demographics
NPI:1912059890
Name:BRADLEY, ANNE M (PHD)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:M
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVENUE
Mailing Address - Street 2:ML 3015
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4336
Mailing Address - Fax:513-636-3677
Practice Address - Street 1:3333 BURNET AVENUE
Practice Address - Street 2:ML 3015
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4336
Practice Address - Fax:513-636-3497
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC853103G00000X, 103T00000X, 103TC0700X, 103TC2200X, 103TH0100X, 103TR0400X
OH6946103TC0700X
OH6948103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPS0385Medicaid
SCPS0385Medicaid