Provider Demographics
NPI:1386974632
Name:CLEARY, BRADFORD ALAN (LMT)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:ALAN
Last Name:CLEARY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:BRAD
Other - Middle Name:
Other - Last Name:CLEARY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2365 NW MARSHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2946
Mailing Address - Country:US
Mailing Address - Phone:503-568-2880
Mailing Address - Fax:
Practice Address - Street 1:7706 SE YAMHILL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3064
Practice Address - Country:US
Practice Address - Phone:503-568-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-09
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11874225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist