Provider Demographics
NPI:1669030284
Name:BRADLEY, THOMAS MARTIN (HIS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:MARTIN
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-7966
Mailing Address - Country:US
Mailing Address - Phone:904-377-6115
Mailing Address - Fax:
Practice Address - Street 1:909 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-7966
Practice Address - Country:US
Practice Address - Phone:904-377-6115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS3361237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty