Provider Demographics
NPI:1245630227
Name:BRADY, DEADRE
Entity type:Individual
Prefix:
First Name:DEADRE
Middle Name:
Last Name:BRADY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 W COLLIN RAYE DR
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-2502
Mailing Address - Country:US
Mailing Address - Phone:870-642-4990
Mailing Address - Fax:870-642-7250
Practice Address - Street 1:1306 W COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-2502
Practice Address - Country:US
Practice Address - Phone:870-642-4990
Practice Address - Fax:870-642-7250
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA 3875225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant