Provider Demographics
NPI:1326602533
Name:BRENNEMAN, BRADLEY (LMT)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:BRENNEMAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 EWALD AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-3403
Mailing Address - Country:US
Mailing Address - Phone:503-378-0068
Mailing Address - Fax:503-378-0068
Practice Address - Street 1:705 EWALD AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-3403
Practice Address - Country:US
Practice Address - Phone:503-378-0068
Practice Address - Fax:503-378-0068
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24471225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist