Provider Demographics
NPI:1518780923
Name:GREEN, BRADLEY ANDREW (PHD)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:ANDREW
Last Name:GREEN
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 1:618 WELLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4663
Mailing Address - Country:US
Mailing Address - Phone:601-297-6591
Mailing Address - Fax:
Practice Address - Street 1:618 WELLINGTON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4663
Practice Address - Country:US
Practice Address - Phone:601-297-6591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39019103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical