Provider Demographics
NPI:1225686017
Name:BEATTY, BRAD
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:BEATTY
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 1:106 TINA DR
Mailing Address - Street 2:
Mailing Address - City:HOLLIDAYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16648-9701
Mailing Address - Country:US
Mailing Address - Phone:814-505-7076
Mailing Address - Fax:
Practice Address - Street 1:106 TINA DR
Practice Address - Street 2:
Practice Address - City:HOLLIDAYSBURG
Practice Address - State:PA
Practice Address - Zip Code:16648-9701
Practice Address - Country:US
Practice Address - Phone:814-505-7076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN006844133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered