Provider Demographics
NPI:1164097697
Name:BANAS, BRADLEY ALLAN (PT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ALLAN
Last Name:BANAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1773 STAR BATT DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-3708
Mailing Address - Country:US
Mailing Address - Phone:248-601-9207
Mailing Address - Fax:
Practice Address - Street 1:2226 CROOKS RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309
Practice Address - Country:US
Practice Address - Phone:248-289-3584
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019953225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist