Basic Information
| Provider Information | |||||||||
| NPI: | 1689616658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 APEX DR | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622491282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184410482 | ||||||||
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| Practice Location | |||||||||
| Address1: | 814 HIGHWAY 36 | ||||||||
| Address2: | |||||||||
| City: | FRENCHBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403228124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063930953 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 05/30/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 004717 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000000333709 | 01 | KY | BC HPTA | OTHER | 000000199364 | 01 | KY | BC OF PARIS | OTHER |