Provider Demographics
NPI:1356690382
Name:JOSEPH, BRADFORD L (PTA)
Entity Type:Individual
Prefix:MR
First Name:BRADFORD
Middle Name:L
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 OAKWOOD DR
Mailing Address - Street 2:APT.#5A
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-3088
Mailing Address - Country:US
Mailing Address - Phone:630-670-8159
Mailing Address - Fax:
Practice Address - Street 1:831 BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60189-8674
Practice Address - Country:US
Practice Address - Phone:630-681-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160004183310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility