Provider Demographics
NPI:1821267550
Name:GARDNER, BRADLEY J (PT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:J
Last Name:GARDNER
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:PO BOX 263
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:NE
Mailing Address - Zip Code:68978-0263
Mailing Address - Country:US
Mailing Address - Phone:402-879-0109
Mailing Address - Fax:866-764-0606
Practice Address - Street 1:308 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:NE
Practice Address - Zip Code:68978-1715
Practice Address - Country:US
Practice Address - Phone:402-879-0109
Practice Address - Fax:866-764-0606
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1102973225100000X
NE1484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist