Provider Demographics
NPI:1467990523
Name:BRADLEY, LORI (OTA)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 W VILLAGE CIR
Mailing Address - Street 2:STE. 1
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67205-9363
Mailing Address - Country:US
Mailing Address - Phone:316-838-2020
Mailing Address - Fax:316-838-7574
Practice Address - Street 1:7550 W VILLAGE CIR
Practice Address - Street 2:STE. 1
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67205-9363
Practice Address - Country:US
Practice Address - Phone:316-838-2020
Practice Address - Fax:316-838-7574
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-04693224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant