Provider Demographics
NPI:1528110855
Name:BRADLEY, KATHY (MPT19913)
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:MPT19913
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 DUSTY ROSE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-3432
Mailing Address - Country:US
Mailing Address - Phone:949-644-2022
Mailing Address - Fax:949-644-1914
Practice Address - Street 1:369 SAN MIGUEL DR
Practice Address - Street 2:STE 265
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7818
Practice Address - Country:US
Practice Address - Phone:949-644-2022
Practice Address - Fax:949-644-1914
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT19913225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT19913CMedicare ID - Type Unspecified
CAS76379Medicare UPIN
CAWPT19913Medicare ID - Type Unspecified