Provider Demographics
NPI:1093851982
Name:WESTBROOK, BRAD THOMAS
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:THOMAS
Last Name:WESTBROOK
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 1:105 LORENE ST
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:AR
Mailing Address - Zip Code:72007-9146
Mailing Address - Country:US
Mailing Address - Phone:501-941-5005
Mailing Address - Fax:
Practice Address - Street 1:1500 WILSON LOOP
Practice Address - Street 2:
Practice Address - City:WARD
Practice Address - State:AR
Practice Address - Zip Code:72176
Practice Address - Country:US
Practice Address - Phone:501-941-5630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1175225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5W794OtherBLUE CROSS BLUE SHEILD