Provider Demographics
NPI:1518140250
Name:BRADLEY, PAIGE W (MS/PT)
Entity Type:Individual
Prefix:MS
First Name:PAIGE
Middle Name:W
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MS/PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 HIGHLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3487
Mailing Address - Country:US
Mailing Address - Phone:859-353-5022
Mailing Address - Fax:859-353-5047
Practice Address - Street 1:314 HIGHLAND PARK DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3487
Practice Address - Country:US
Practice Address - Phone:859-353-5022
Practice Address - Fax:859-353-5047
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0051422251P0200X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100219070Medicaid
KY000000783289OtherANTHEM PIN
KY7100219070Medicaid