Provider Demographics
NPI:1346839206
Name:SCARBOROUGH, BRADLEY (LPTA)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:SCARBOROUGH
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39042-2906
Mailing Address - Country:US
Mailing Address - Phone:601-278-9985
Mailing Address - Fax:
Practice Address - Street 1:2611 JONES AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-2650
Practice Address - Country:US
Practice Address - Phone:719-564-1735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCP003218A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant