Provider Demographics
NPI:1134523475
Name:PRALLE, BRAD
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:PRALLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13302 43RD AVE
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729
Mailing Address - Country:US
Mailing Address - Phone:715-579-0666
Mailing Address - Fax:
Practice Address - Street 1:8014 BETHEL RD
Practice Address - Street 2:
Practice Address - City:ARPIN
Practice Address - State:WI
Practice Address - Zip Code:54410-9558
Practice Address - Country:US
Practice Address - Phone:715-652-2103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2198-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant