Provider Demographics
NPI:1932533262
Name:LIBBY, BRADLEY (DPT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:LIBBY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:797 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1000
Mailing Address - Country:US
Mailing Address - Phone:207-992-4042
Mailing Address - Fax:207-992-4043
Practice Address - Street 1:797 WILSON ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1000
Practice Address - Country:US
Practice Address - Phone:207-992-4042
Practice Address - Fax:207-992-4043
Is Sole Proprietor?:No
Enumeration Date:2013-08-22
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT4035174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPT4035OtherPHYSICAL THERAPY LICENCE