Provider Demographics
NPI:1275764664
Name:LANGLEY, BRADLEY
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:LANGLEY
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 1:225 LAKE POINT CV
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38066-3500
Mailing Address - Country:US
Mailing Address - Phone:731-217-7391
Mailing Address - Fax:
Practice Address - Street 1:10992 HIGHWAY 51 S
Practice Address - Street 2:SUITE 100
Practice Address - City:ATOKA
Practice Address - State:TN
Practice Address - Zip Code:38004-4944
Practice Address - Country:US
Practice Address - Phone:901-837-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8456225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist