Provider Demographics
NPI:1013985613
Name:BRUSH, BRADLEY C (ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:C
Last Name:BRUSH
Suffix:
Gender:M
Credentials:ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 S GREEN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1103
Mailing Address - Country:US
Mailing Address - Phone:618-833-4441
Mailing Address - Fax:
Practice Address - Street 1:305 W JACKSON ST
Practice Address - Street 2:SUITE LL02
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1474
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-529-0403
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096-0003082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer