Provider Demographics
NPI:1245453737
Name:WOLTER, BRAD SCOTT (PT)
Entity type:Individual
Prefix:MR
First Name:BRAD
Middle Name:SCOTT
Last Name:WOLTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:BRADFORD
Other - Middle Name:SCOTT
Other - Last Name:WOLTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:173 N HARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2622
Mailing Address - Country:US
Mailing Address - Phone:773-213-8418
Mailing Address - Fax:
Practice Address - Street 1:173 N HARVEY AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2622
Practice Address - Country:US
Practice Address - Phone:773-213-8418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070007821174400000X
IL070.007821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist