Basic Information
| Provider Information | |||||||||
| NPI: | 1881773422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REYNOLDS | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 W NORTH RIVER DR | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093230066 | ||||||||
| FaxNumber: | 5093230067 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 W NORTH RIVER DR | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992012284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5093230066 | ||||||||
| FaxNumber: | 5093230067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | PT00002713 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8346330 | 05 | WA | MEDICAID |