Provider Demographics
NPI:1639493075
Name:BRADLEY, KIRSTEN (KIRSTEN BRADLEY)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:KIRSTEN BRADLEY
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:3945 LOIS ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-5832
Mailing Address - Country:US
Mailing Address - Phone:336-785-0096
Mailing Address - Fax:
Practice Address - Street 1:142 BERMUDA VILLAGE DR
Practice Address - Street 2:ATTN: PT/OT DEPARTMENT
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-7867
Practice Address - Country:US
Practice Address - Phone:336-998-6112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-14
Last Update Date:2010-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5461225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist