Provider Demographics
NPI:1689186736
Name:BRADLEY, KELLY (MSPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3037 KENSINGTON CT
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-4170
Mailing Address - Country:US
Mailing Address - Phone:202-320-5025
Mailing Address - Fax:
Practice Address - Street 1:7455 SW BRIDGEPORT RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-7252
Practice Address - Country:US
Practice Address - Phone:503-968-1704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR62152225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist