Provider Demographics
NPI:1649209149
Name:HARDESTY, BRADLEY PHILLIP (MPT)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:PHILLIP
Last Name:HARDESTY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8306 SATURN PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-2525
Mailing Address - Country:US
Mailing Address - Phone:605-431-0709
Mailing Address - Fax:
Practice Address - Street 1:3650 MANSELL RD STE 300
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-3068
Practice Address - Country:US
Practice Address - Phone:877-896-3660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1175225100000X
TX1141208225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4996113OtherBLUE CROSS BLUE SHIELD
SD5834140Medicaid
SD4996113OtherBLUE CROSS BLUE SHIELD