Provider Demographics
NPI:1629740352
Name:KEGEBEIN, BRAD DAVID
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:DAVID
Last Name:KEGEBEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 PARK GREEN DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-3375
Mailing Address - Country:US
Mailing Address - Phone:248-417-8919
Mailing Address - Fax:
Practice Address - Street 1:242 PARK GREEN DR
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-3375
Practice Address - Country:US
Practice Address - Phone:248-417-8919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010102225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist