Provider Demographics
NPI:1710402854
Name:KELLER, BRADLEY GENE (DPT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:GENE
Last Name:KELLER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7825 3RD ST N
Mailing Address - Street 2:STE 105
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5444
Mailing Address - Country:US
Mailing Address - Phone:952-835-4512
Mailing Address - Fax:888-425-0398
Practice Address - Street 1:17599 KENWOOD TRL STE 200
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-4228
Practice Address - Country:US
Practice Address - Phone:952-835-4512
Practice Address - Fax:888-425-0398
Is Sole Proprietor?:No
Enumeration Date:2017-08-10
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10768225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist