Provider Demographics
NPI:1184873580
Name:THOMAS, CLINT BRADLEY (OT, CHT)
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:BRADLEY
Last Name:THOMAS
Suffix:
Gender:M
Credentials:OT, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:3575 KEITH ST NW
Practice Address - Street 2:STE 205
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4324
Practice Address - Country:US
Practice Address - Phone:423-559-0444
Practice Address - Fax:423-559-0103
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT2819225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1506784Medicaid