Provider Demographics
NPI:1982608550
Name:ALLEN, BRAD STACY (PT)
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:STACY
Last Name:ALLEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5521 50TH ST APT 807
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-1647
Mailing Address - Country:US
Mailing Address - Phone:979-450-4602
Mailing Address - Fax:
Practice Address - Street 1:4214 98TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-3957
Practice Address - Country:US
Practice Address - Phone:806-712-7878
Practice Address - Fax:806-722-7878
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1085595225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX058642202Medicaid
TX058642202Medicaid
TXTBX127103Medicare UPIN