Provider Demographics
NPI:1407812019
Name:SMITH, BRADLEY JAMES (PT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JAMES
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-0551
Mailing Address - Country:US
Mailing Address - Phone:707-279-0881
Mailing Address - Fax:707-279-0887
Practice Address - Street 1:5289 STATE ST
Practice Address - Street 2:
Practice Address - City:KELSEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95451
Practice Address - Country:US
Practice Address - Phone:707-279-0881
Practice Address - Fax:707-279-0887
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist