NPIMap

Individual provider Active NPI

Bradley William Samuel, PHD

  • Clinical Psychologist
  • Albuquerque, NM
National Provider Identifier
1255363586
Registry record updated May 22, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
License
738 Issued in NM
Practice address
2400 Tucker NE
Albuquerque, NM 87131-0001
Phone
(505) 272-1734
Fax
(505) 272-6308
NPI assigned
Jul 7, 2006
Last updated
May 22, 2012By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on May 22, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Psychologist 103TC0700X 738 NM Primary

Addresses

Primary practice location

2400 Tucker NE
Albuquerque, NM 87131-0001

Mailing address

933 Bradbury Dr SE
Suite 2222
Albuquerque, NM 87106-4374
Phone (505) 272-3120

Other identifiers 3

IdentifierTypeStateIssuer
09702784MedicaidCO
955627MedicaidAZ
NM01JB06OtherNMBLUE SHIELD

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Philosophy

State licenses

LicenseStateTypeSpecialty
738NMMDClinical Psychologist

Practice roles

OrganizationSpecialtyStatusNew patients
Unm Hospital Past Accepting new patients

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152230400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1337644800000",
    "number": "1255363586",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "933 BRADBURY DR SE",
            "address_2": "SUITE 2222",
            "city": "ALBUQUERQUE",
            "state": "NM",
            "postal_code": "871064374",
            "telephone_number": "505-272-3120",
            "fax_number": "505-272-8060"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2400 TUCKER NE",
            "city": "ALBUQUERQUE",
            "state": "NM",
            "postal_code": "871310001",
            "telephone_number": "505-272-1734",
            "fax_number": "505-272-6308"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SAMUEL",
        "first_name": "BRADLEY",
        "middle_name": "WILLIAM",
        "name_prefix": "Dr.",
        "credential": "PHD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-07-07",
        "last_updated": "2012-05-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "NM",
            "license": "738",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "09702784",
            "state": "CO"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "955627",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE SHIELD",
            "identifier": "NM01JB06",
            "state": "NM"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Albuquerque, NM

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 22, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.