Provider Demographics
NPI:1568924348
Name:VICKERS, THOMAS BRADLEY (DPT, ATC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BRADLEY
Last Name:VICKERS
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11911 CORNELIUS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-4004
Mailing Address - Country:US
Mailing Address - Phone:904-234-4446
Mailing Address - Fax:
Practice Address - Street 1:1852 SW BARNETT WAY STE 101
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-6953
Practice Address - Country:US
Practice Address - Phone:386-752-7332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305214533225100000X
KY008502225100000X
SC10947225100000X
FLAL45632255A2300X
FLPT37213225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer