Provider Demographics
NPI:1639554546
Name:BRADY, CHANCE (PT)
Entity Type:Individual
Prefix:
First Name:CHANCE
Middle Name:
Last Name:BRADY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 N GRANDVIEW AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-1621
Mailing Address - Country:US
Mailing Address - Phone:432-550-4700
Mailing Address - Fax:432-550-4715
Practice Address - Street 1:1365 W UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79764-7121
Practice Address - Country:US
Practice Address - Phone:432-580-0011
Practice Address - Fax:432-580-0044
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1262088225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX354385201Medicaid
TX354385201Medicaid