Provider Demographics
NPI:1831512425
Name:GRECO, BRADLEY NOBILE (LOTR)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:NOBILE
Last Name:GRECO
Suffix:
Gender:M
Credentials:LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3348 CASTLE DR
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2918
Mailing Address - Country:US
Mailing Address - Phone:504-909-3015
Mailing Address - Fax:
Practice Address - Street 1:1101 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE S 750
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3147
Practice Address - Country:US
Practice Address - Phone:504-340-6976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-02
Last Update Date:2014-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200471225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist