Provider Demographics
NPI:1710381017
Name:MARLENE BRADNOCK
Entity Type:Organization
Organization Name:MARLENE BRADNOCK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRADNOCK
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:347-357-7881
Mailing Address - Street 1:17818 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-2716
Mailing Address - Country:US
Mailing Address - Phone:347-357-7881
Mailing Address - Fax:
Practice Address - Street 1:178-18 120 AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434
Practice Address - Country:US
Practice Address - Phone:347-357-7881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002442261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy