Provider Demographics
NPI:1902021538
Name:THOMAS, BRAD L (PT)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:L
Last Name:THOMAS
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 1:169 SPRING CREEK PARK WAY
Mailing Address - Street 2:SUITE 140
Mailing Address - City:PROVIDNCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332
Mailing Address - Country:US
Mailing Address - Phone:435-755-8500
Mailing Address - Fax:435-755-2836
Practice Address - Street 1:169 SPRING CREEK PARK WAY
Practice Address - Street 2:SUITE 140
Practice Address - City:PROVIDNCE
Practice Address - State:UT
Practice Address - Zip Code:84332
Practice Address - Country:US
Practice Address - Phone:435-755-8500
Practice Address - Fax:435-755-2836
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT871176802401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTN0741Medicaid