Provider Demographics
NPI:1073077723
Name:BRADBERRY, DIANE (LPTA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:BRADBERRY
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 BACKWOODS WAY
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-6951
Mailing Address - Country:US
Mailing Address - Phone:931-248-0291
Mailing Address - Fax:
Practice Address - Street 1:55 W LAKE RD
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:TN
Practice Address - Zip Code:38578-3002
Practice Address - Country:US
Practice Address - Phone:931-248-0291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3294225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant