Provider Demographics
NPI:1093438467
Name:STALDER, BRADLEY R
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:R
Last Name:STALDER
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 1:411 N STATE ROUTE 2
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-2711
Mailing Address - Country:US
Mailing Address - Phone:304-455-5515
Mailing Address - Fax:
Practice Address - Street 1:411 N STATE ROUTE 2
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-2711
Practice Address - Country:US
Practice Address - Phone:304-455-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001686225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant