Provider Demographics
NPI:1851373989
Name:BRADLEY, KATHLEEN MARIE (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:CONLEY
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSPT
Mailing Address - Street 1:PO BOX 2190
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97709-2190
Mailing Address - Country:US
Mailing Address - Phone:541-390-7438
Mailing Address - Fax:541-389-6272
Practice Address - Street 1:1045 NW BOND ST STE 203
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-2064
Practice Address - Country:US
Practice Address - Phone:541-390-7438
Practice Address - Fax:541-389-6272
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2009-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4629225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR299843Medicaid
OR804449008OtherBCBS
ORH254808OtherPACIFIC SOURCE
333058OtherPROVIDENCE
5512827OtherFIRST HEALTH
OR299843Medicaid