Provider Demographics
NPI:1255933545
Name:BRAGDON, COLBY E
Entity type:Individual
Prefix:
First Name:COLBY
Middle Name:E
Last Name:BRAGDON
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 1:165 N CANAL ST APT 619
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1525
Mailing Address - Country:US
Mailing Address - Phone:515-402-6366
Mailing Address - Fax:
Practice Address - Street 1:2235 N SHEFFIELD AVE RM 120
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-6589
Practice Address - Country:US
Practice Address - Phone:773-525-4966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL070.025532225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist