Provider Demographics
NPI:1346088515
Name:DIAZ, BRAD (PTA)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:DIAZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15200 LA PALOMA WAY
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-9525
Mailing Address - Country:US
Mailing Address - Phone:530-440-2047
Mailing Address - Fax:
Practice Address - Street 1:15200 LA PALOMA WAY
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-9525
Practice Address - Country:US
Practice Address - Phone:530-440-2047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9653225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty