Provider Demographics
NPI:1578867552
Name:BRADLEY, KEVIN LYLE (LMT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:LYLE
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 1:307 MENDEZ DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-1514
Mailing Address - Country:US
Mailing Address - Phone:941-544-0465
Mailing Address - Fax:
Practice Address - Street 1:2429 MANATEE AVE E UNIT 3
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-2407
Practice Address - Country:US
Practice Address - Phone:941-544-0465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA59241225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist