Provider Demographics
NPI:1801044417
Name:BRADLEY, BRUCE H (OT)
Entity Type:Individual
Prefix:MS
First Name:BRUCE
Middle Name:H
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 PINE ST
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-1634
Mailing Address - Country:US
Mailing Address - Phone:618-273-2327
Mailing Address - Fax:618-273-5501
Practice Address - Street 1:1201 PINE ST
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-1634
Practice Address - Country:US
Practice Address - Phone:618-273-2327
Practice Address - Fax:618-273-5501
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056003538225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist