Provider Demographics
NPI:1063999381
Name:BRADY, CAROLYN (PT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:BRADY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5901 W BEHREND DR APT 2146
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-6955
Mailing Address - Country:US
Mailing Address - Phone:815-721-0038
Mailing Address - Fax:
Practice Address - Street 1:430 MILWAUKEE AVE STE AA
Practice Address - Street 2:
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-3016
Practice Address - Country:US
Practice Address - Phone:847-821-8300
Practice Address - Fax:847-821-9300
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13345-24225100000X
NCP18981225100000X
AZLPT30150225100000X
IL070024404225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist