Provider Demographics
NPI:1689616658
Name:DAVIDSON, BRADLEY J (PT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:DAVIDSON
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 1:15 APEX DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249-1282
Mailing Address - Country:US
Mailing Address - Phone:618-441-0482
Mailing Address - Fax:
Practice Address - Street 1:814 HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:FRENCHBURG
Practice Address - State:KY
Practice Address - Zip Code:40322-8124
Practice Address - Country:US
Practice Address - Phone:606-393-0953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2017-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004717225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000333709OtherBC HPTA
KY000000199364OtherBC OF PARIS
KY000000333709OtherBC HPTA