Provider Demographics
NPI:1861827602
Name:BRADT, KEVIN A (PT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:A
Last Name:BRADT
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 1:3708 NORTHSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210
Mailing Address - Country:US
Mailing Address - Phone:478-254-5303
Mailing Address - Fax:478-254-5324
Practice Address - Street 1:3708 NORTHSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210
Practice Address - Country:US
Practice Address - Phone:478-254-5303
Practice Address - Fax:478-254-5324
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011234225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist