Provider Demographics
NPI:1619291960
Name:BRADLEY, CARMELLETTA (COTA)
Entity Type:Individual
Prefix:
First Name:CARMELLETTA
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3062 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4401
Mailing Address - Country:US
Mailing Address - Phone:773-437-4740
Mailing Address - Fax:773-530-0809
Practice Address - Street 1:3062 E 91ST ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4401
Practice Address - Country:US
Practice Address - Phone:773-437-4740
Practice Address - Fax:773-530-0809
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32001497A224Z00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator