Basic Information
| Provider Information | |||||||||
| NPI: | 1710544937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHALKO | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70689 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841700689 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019878602 | ||||||||
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| Practice Location | |||||||||
| Address1: | 441 S REDWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841043539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019751403 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2019 | ||||||||
| LastUpdateDate: | 05/22/2019 | ||||||||
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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 | 11250165-2401 | UT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 11250165-2401 | 01 | UT | UTAH OCCUPATIONAL THERAPIST LICENSE | OTHER |