Provider Demographics
NPI:1073129425
Name:DUBEY, BRADLEY THEODORE
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:THEODORE
Last Name:DUBEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6533 CANNON FARMS DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8284
Mailing Address - Country:US
Mailing Address - Phone:616-240-4802
Mailing Address - Fax:
Practice Address - Street 1:6533 CANNON FARMS DR NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-8284
Practice Address - Country:US
Practice Address - Phone:616-240-4802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003281225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant