Provider Demographics
NPI:1306021928
Name:ROBB, BRADLEY ETHAN (OTR)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:ETHAN
Last Name:ROBB
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 W SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-1748
Mailing Address - Country:US
Mailing Address - Phone:715-720-7646
Mailing Address - Fax:
Practice Address - Street 1:1850 11TH ST
Practice Address - Street 2:
Practice Address - City:FENNIMORE
Practice Address - State:WI
Practice Address - Zip Code:53809-1612
Practice Address - Country:US
Practice Address - Phone:608-822-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2835-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist