Provider Demographics
NPI:1528604121
Name:BRADLEY, KYLE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 WHITE OAK DR
Mailing Address - Street 2:
Mailing Address - City:JIM THORPE
Mailing Address - State:PA
Mailing Address - Zip Code:18229-9515
Mailing Address - Country:US
Mailing Address - Phone:610-360-0179
Mailing Address - Fax:
Practice Address - Street 1:2092 W PENN PIKE
Practice Address - Street 2:
Practice Address - City:NEW RINGGOLD
Practice Address - State:PA
Practice Address - Zip Code:17960-9398
Practice Address - Country:US
Practice Address - Phone:570-645-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT026669225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist