Provider Demographics
NPI:1003222068
Name:LEAFBLAD, BRADLEY (PT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:LEAFBLAD
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 RADIO DR
Mailing Address - Street 2:#120
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-8409
Mailing Address - Country:US
Mailing Address - Phone:651-735-6100
Mailing Address - Fax:
Practice Address - Street 1:1000 RADIO DR
Practice Address - Street 2:# 120
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-8409
Practice Address - Country:US
Practice Address - Phone:651-735-6100
Practice Address - Fax:651-735-6106
Is Sole Proprietor?:No
Enumeration Date:2014-07-10
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6430225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist