Provider Demographics
NPI:1821410887
Name:SMALL, BRADE
Entity Type:Individual
Prefix:
First Name:BRADE
Middle Name:
Last Name:SMALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 TITAN ST
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-8426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 S CHERRY ST
Practice Address - Street 2:SUITE 640
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80246-1226
Practice Address - Country:US
Practice Address - Phone:303-333-3493
Practice Address - Fax:303-333-1184
Is Sole Proprietor?:No
Enumeration Date:2014-01-10
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60338175225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist