Provider Demographics
NPI:1073866851
Name:BRADBURY, KELLI PATRICE (DPT)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:PATRICE
Last Name:BRADBURY
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14052 N GREENBRIAR RD
Mailing Address - Street 2:
Mailing Address - City:CARTERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62918-3164
Mailing Address - Country:US
Mailing Address - Phone:618-303-1290
Mailing Address - Fax:
Practice Address - Street 1:14052 N GREENBRIAR RD
Practice Address - Street 2:
Practice Address - City:CARTERVILLE
Practice Address - State:IL
Practice Address - Zip Code:62918-3164
Practice Address - Country:US
Practice Address - Phone:618-303-1290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05009976A225100000X
TN9515225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN9515OtherLICENSE
IN05009976AOtherLICENSE