Provider Demographics
NPI:1376577874
Name:LEAVELLE, BRADLEY JON (MSPT, OCS)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JON
Last Name:LEAVELLE
Suffix:
Gender:M
Credentials:MSPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 3RD ST N
Mailing Address - Street 2:STE 105
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5444
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:888-425-0398
Practice Address - Street 1:1029 W CENTRAL ENTRANCE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-5477
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:888-425-0398
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6075225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40307800Medicaid
HP38184OtherHEALTHPARTNERS