Basic Information
| Provider Information | |||||||||
| NPI: | 1780883223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRAD | ||||||||
| FirstName: | NANCY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7622 MCLAUGHLIN RD | ||||||||
| Address2: | |||||||||
| City: | PEYTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808314710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7194953133 | ||||||||
| FaxNumber: | 7194958685 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 ANDERSON AVE | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224279401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8049944263 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2007 | ||||||||
| LastUpdateDate: | 05/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTL.0017430 | CO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305204322 | VA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.