Provider Demographics
NPI:1174251201
Name:GOSS, BRADY (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRADY
Middle Name:
Last Name:GOSS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 E WILSHIRE AVE STE G4
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1960
Mailing Address - Country:US
Mailing Address - Phone:562-944-0351
Mailing Address - Fax:
Practice Address - Street 1:110 E WILSHIRE AVE STE G4
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1960
Practice Address - Country:US
Practice Address - Phone:562-944-0351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY26424103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical