Provider Demographics
NPI:1811667025
Name:DAVIS, BRADLEY NELSON (LMBT)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:NELSON
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 MASSEY RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-9113
Mailing Address - Country:US
Mailing Address - Phone:919-714-3918
Mailing Address - Fax:
Practice Address - Street 1:3605 MASSEY RIDGE CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-9113
Practice Address - Country:US
Practice Address - Phone:919-714-3918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-18
Last Update Date:2021-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5788225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist