Provider Demographics
NPI:1295446383
Name:BEADLE, KEVIN BLAKE (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:BLAKE
Last Name:BEADLE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27158 US HIGHWAY 150
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-9126
Mailing Address - Country:US
Mailing Address - Phone:309-265-8172
Mailing Address - Fax:
Practice Address - Street 1:5601 W EUGIE AVE STE 202
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1256
Practice Address - Country:US
Practice Address - Phone:602-843-8436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.027038225100000X
AZLPT-32707225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist