Provider Demographics
NPI:1801489828
Name:RUSSELL, BRADLEY P (DPT)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:P
Last Name:RUSSELL
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:4511 ROUTE 71
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-7416
Practice Address - Country:US
Practice Address - Phone:630-554-7815
Practice Address - Fax:630-554-4849
Is Sole Proprietor?:No
Enumeration Date:2021-02-19
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.025309225100000X
MAPTL26498225100000X
NH5234225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist