Provider Demographics
NPI:1558762088
Name:BACANAYA, BRADLEY JUDE (PT)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:JUDE
Last Name:BACANAYA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 COMLY RD
Mailing Address - Street 2:APT K31
Mailing Address - City:LINCOLN PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07035-1166
Mailing Address - Country:US
Mailing Address - Phone:973-707-8249
Mailing Address - Fax:
Practice Address - Street 1:1070 CLIFTON AVE
Practice Address - Street 2:SUITE A1
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3619
Practice Address - Country:US
Practice Address - Phone:973-246-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2016-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01194900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist