Provider Demographics
NPI:1265760029
Name:BRADLEY, BRIAN MICHAEL (MS, ATC, LAT, CSCS)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MICHAEL
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:MS, ATC, LAT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 ORIENTA AVE
Mailing Address - Street 2:SUITE 1015
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5619
Mailing Address - Country:US
Mailing Address - Phone:407-332-7816
Mailing Address - Fax:
Practice Address - Street 1:745 ORIENTA AVE
Practice Address - Street 2:SUITE 1015
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5619
Practice Address - Country:US
Practice Address - Phone:407-332-7816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-05
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL25222255A2300X
MA19982255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer