Provider Demographics
NPI:1215255070
Name:BRADY, WANDA KAY (LMT)
Entity type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:KAY
Last Name:BRADY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4563 TERRANG TRL
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-2742
Mailing Address - Country:US
Mailing Address - Phone:815-633-8757
Mailing Address - Fax:
Practice Address - Street 1:4563 TERRANG TRL
Practice Address - Street 2:
Practice Address - City:MACHESNEY PARK
Practice Address - State:IL
Practice Address - Zip Code:61115-2742
Practice Address - Country:US
Practice Address - Phone:815-633-8757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.000304225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist