Provider Demographics
NPI:1063990877
Name:HARDY II, BRIAN (DPT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:HARDY II
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 1:600 52ND ST STE 240
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53140-3423
Mailing Address - Country:US
Mailing Address - Phone:888-488-8714
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:3620 57TH AVE STE 400
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-4924
Practice Address - Country:US
Practice Address - Phone:262-925-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14316-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist