Provider Demographics
NPI:1073907135
Name:PRUETT, BRADLY (MS, ATC)
Entity Type:Individual
Prefix:
First Name:BRADLY
Middle Name:
Last Name:PRUETT
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7610 BETH RD APT C
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23228-3539
Mailing Address - Country:US
Mailing Address - Phone:434-210-0935
Mailing Address - Fax:
Practice Address - Street 1:1300 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23284-9089
Practice Address - Country:US
Practice Address - Phone:804-828-2321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260012192255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer