Provider Demographics
NPI:1518055714
Name:PROFITT, BRAD LEE (PT, DPT, CSCS, DC,)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:LEE
Last Name:PROFITT
Suffix:
Gender:M
Credentials:PT, DPT, CSCS, DC,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 DIEDERICH BLVD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:KY
Mailing Address - Zip Code:41169-1718
Mailing Address - Country:US
Mailing Address - Phone:606-836-6683
Mailing Address - Fax:
Practice Address - Street 1:1451 DIEDERICH BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1718
Practice Address - Country:US
Practice Address - Phone:606-388-2173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY250594111N00000X
KY005907225100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
7562230OtherAETNA
KY000000216813OtherANTHEM 12 DIGIT PIN
4402131OtherUNITED HEALTHCARE
KY350054419OtherRR MEDICARE NUMBER
KY85001504Medicaid
KY000000216813OtherANTHEM 12 DIGIT PIN
U81659Medicare UPIN