Provider Demographics
NPI:1730783952
Name:BRADLEY, DANIEL ADAM (PT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:ADAM
Last Name:BRADLEY
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 1:1102 FAIRFIELD CT
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-1051
Mailing Address - Country:US
Mailing Address - Phone:504-491-5872
Mailing Address - Fax:
Practice Address - Street 1:505 ROBERT BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-1645
Practice Address - Country:US
Practice Address - Phone:985-643-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04108225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist