Provider Demographics
NPI:1457643207
Name:BRADLEY, THERESA LEE (PTA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LEE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8309 BARTLEY CIR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75025-4319
Mailing Address - Country:US
Mailing Address - Phone:469-879-7531
Mailing Address - Fax:972-818-3889
Practice Address - Street 1:8309 BARTLEY CIR
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75025-4319
Practice Address - Country:US
Practice Address - Phone:469-879-7531
Practice Address - Fax:972-818-3889
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2051740174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist