Provider Demographics
NPI:1164686531
Name:BRADLEY, ANGELA CHRYSTAL (MPT)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:CHRYSTAL
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 911230
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75391-1230
Mailing Address - Country:US
Mailing Address - Phone:972-997-8000
Mailing Address - Fax:972-234-0813
Practice Address - Street 1:901 W 38TH ST STE 300
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705
Practice Address - Country:US
Practice Address - Phone:512-421-4100
Practice Address - Fax:512-419-0924
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27415225100000X
TX1131548225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX406838901Medicaid