Provider Demographics
NPI:1174175558
Name:BROWN, BRADLEY SCOTT (MT)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:SCOTT
Last Name:BROWN
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8109 N WAYNE BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-5031
Mailing Address - Country:US
Mailing Address - Phone:208-667-7463
Mailing Address - Fax:208-762-6385
Practice Address - Street 1:8109 N WAYNE BLVD
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-5031
Practice Address - Country:US
Practice Address - Phone:208-667-7463
Practice Address - Fax:208-762-6385
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-2367225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMASG-2367OtherMT LICENSE