Provider Demographics
NPI:1497411649
Name:SHOLLENBARGER, BRADY
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:
Last Name:SHOLLENBARGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4624 JERI CV
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-8190
Mailing Address - Country:US
Mailing Address - Phone:870-215-1947
Mailing Address - Fax:
Practice Address - Street 1:244 US HIGHWAY 68 E
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-7568
Practice Address - Country:US
Practice Address - Phone:870-215-1947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5004225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist