Provider Demographics
NPI:1093589624
Name:BURKE, BRADY RUSSELL (DPT)
Entity type:Individual
Prefix:DR
First Name:BRADY
Middle Name:RUSSELL
Last Name:BURKE
Suffix:
Gender:
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 LUCIEN WAY STE 325
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7020
Mailing Address - Country:US
Mailing Address - Phone:800-774-7785
Mailing Address - Fax:
Practice Address - Street 1:8040 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-2002
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-14
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501303471225100000X
WAPT61662714225100000X
GAPT016993225100000X
FL40974225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist