Provider Demographics
NPI:1134443005
Name:WILSON, BRADLEY LEMOND (LMT, COTA/L)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:LEMOND
Last Name:WILSON
Suffix:
Gender:M
Credentials:LMT, COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28415 N DUCK CREEK AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:IN
Mailing Address - Zip Code:46031-9747
Mailing Address - Country:US
Mailing Address - Phone:317-316-7128
Mailing Address - Fax:
Practice Address - Street 1:10293 N MERIDIAN ST STE 125
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46290-1123
Practice Address - Country:US
Practice Address - Phone:317-316-7128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Z00000X
INMT2207871225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1070991OtherNATIONAL BOARD OF CERTIFICATION IN OCCUPATIONAL THERAPY, INC.
INMT2207871OtherINDIANA PROFESSIONAL LICENSING AGENCY
IN32001316AOtherINDIANA PROFESSIONAL LICENSING AGENCY: OCCUPATIONAL THERAPY COMMITTEE