Provider Demographics
NPI:1104424407
Name:BRADBURY, KATHRYN R (PHD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:R
Last Name:BRADBURY
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 1:200 PRESIDENTIAL WAY UNIT 2418
Mailing Address - Street 2:
Mailing Address - City:WOBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01801-0068
Mailing Address - Country:US
Mailing Address - Phone:860-965-1775
Mailing Address - Fax:
Practice Address - Street 1:26 CHESTNUT ST STE 2E
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-3600
Practice Address - Country:US
Practice Address - Phone:978-749-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3279103TC0700X
MA11369103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical