Provider Demographics
NPI:1629200548
Name:BLEVINS, BRADLEY M (PTA)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:M
Last Name:BLEVINS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 GREENBRIAR DR
Mailing Address - Street 2:SUITE B-2
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6421
Mailing Address - Country:US
Mailing Address - Phone:217-546-3301
Mailing Address - Fax:
Practice Address - Street 1:2921 GREENBRIAR DR
Practice Address - Street 2:SUITE B-2
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6421
Practice Address - Country:US
Practice Address - Phone:217-546-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.005226225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant