Provider Demographics
NPI:1659991206
Name:CONEHARRISON, BRADLEY RYAN (LMT)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:RYAN
Last Name:CONEHARRISON
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:MR
Other - First Name:BRADLEY
Other - Middle Name:RYAN
Other - Last Name:CONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:453 S SHAMOKIN ST
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN
Mailing Address - State:PA
Mailing Address - Zip Code:17872-6407
Mailing Address - Country:US
Mailing Address - Phone:272-241-9069
Mailing Address - Fax:
Practice Address - Street 1:453 S SHAMOKIN ST
Practice Address - Street 2:
Practice Address - City:SHAMOKIN
Practice Address - State:PA
Practice Address - Zip Code:17872-6407
Practice Address - Country:US
Practice Address - Phone:272-241-9069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-23
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG013254225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty