Provider Demographics
NPI:1497034995
Name:SMITH, BRADLEY MICHAEL (ATP)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6209 TRAIL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-3405
Mailing Address - Country:US
Mailing Address - Phone:817-793-3773
Mailing Address - Fax:
Practice Address - Street 1:6209 TRAIL LAKE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-3405
Practice Address - Country:US
Practice Address - Phone:817-793-3773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXATP13910225CA2400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225CA2400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation CounselorAssistive Technology Practitioner