Provider Demographics
NPI:1255983516
Name:DECK, BRADLEY JAY
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JAY
Last Name:DECK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2386B HICKORY NUT LN
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2841
Mailing Address - Country:US
Mailing Address - Phone:540-247-9163
Mailing Address - Fax:
Practice Address - Street 1:2978 CENTREVILLE RD
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-6253
Practice Address - Country:US
Practice Address - Phone:703-934-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119-008157225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist