Provider Demographics
NPI:1497519391
Name:BRADFORD, PATRICK DEWAYNE JR (OTR/L)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:DEWAYNE
Last Name:BRADFORD
Suffix:JR
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 VINE ST APT 234S
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7375
Mailing Address - Country:US
Mailing Address - Phone:909-236-9777
Mailing Address - Fax:
Practice Address - Street 1:845 S BURLINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-4296
Practice Address - Country:US
Practice Address - Phone:213-381-5585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25824225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation