Provider Demographics
NPI:1518317981
Name:BRADLEY, DOUGLAS (LMT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 933
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59903-0933
Mailing Address - Country:US
Mailing Address - Phone:406-250-0707
Mailing Address - Fax:
Practice Address - Street 1:1500 AIRPORT RD STE 5
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-5748
Practice Address - Country:US
Practice Address - Phone:406-250-0707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT293225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT329460OtherMEDICAID WAIVER