Provider Demographics
NPI:1205892486
Name:TYTHCOTT, BRADLEY A (PT)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:TYTHCOTT
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 1:615 QUINLAN DR
Mailing Address - Street 2:UNIT G
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-1809
Mailing Address - Country:US
Mailing Address - Phone:262-746-9785
Mailing Address - Fax:
Practice Address - Street 1:N53W24950 S CORPORATE CIR
Practice Address - Street 2:SUITE 2
Practice Address - City:SUSSEX
Practice Address - State:WI
Practice Address - Zip Code:53089-4374
Practice Address - Country:US
Practice Address - Phone:126-224-6300
Practice Address - Fax:262-246-4255
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9592225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40465300Medicaid
WIQ38424Medicare UPIN
WI0031Medicare ID - Type Unspecified
WI81030Medicare PIN