Provider Demographics
NPI:1295701555
Name:ROBERTS, BRADLEY SHAWN (PT)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:SHAWN
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:134 CORDS BRIDGE RD NE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-9051
Mailing Address - Country:US
Mailing Address - Phone:478-452-6252
Mailing Address - Fax:478-452-6255
Practice Address - Street 1:571 HAMMOCK RD NW
Practice Address - Street 2:SUITE 106
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-7184
Practice Address - Country:US
Practice Address - Phone:478-452-6252
Practice Address - Fax:478-452-6255
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6122225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
65BBBQCMedicare ID - Type Unspecified