Provider Demographics
NPI:1326442856
Name:WATSON, BRADLEY (MS, AT, ATC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:MS, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8103 AUTUMN WOODS TRL
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3291
Mailing Address - Country:US
Mailing Address - Phone:419-217-8145
Mailing Address - Fax:
Practice Address - Street 1:799 N HEWITT RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1701
Practice Address - Country:US
Practice Address - Phone:734-487-8498
Practice Address - Fax:734-487-5173
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL5232612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer