Provider Demographics
NPI:1437274107
Name:BRADBERRY, AUTUMN A (OTR)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:A
Last Name:BRADBERRY
Suffix:
Gender:F
Credentials:OTR
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 382
Mailing Address - Street 2:
Mailing Address - City:CLIFF
Mailing Address - State:NM
Mailing Address - Zip Code:88028-0382
Mailing Address - Country:US
Mailing Address - Phone:505-535-2498
Mailing Address - Fax:
Practice Address - Street 1:#14 BLACK MOUNTAIN ROAD
Practice Address - Street 2:
Practice Address - City:CLIFF
Practice Address - State:NM
Practice Address - Zip Code:88028
Practice Address - Country:US
Practice Address - Phone:505-590-0824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2263225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist