Provider Demographics
NPI:1972785269
Name:BRADLEY, LAWRENCE M
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:M
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 W MAIN ST
Mailing Address - Street 2:STE B
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-1454
Mailing Address - Country:US
Mailing Address - Phone:330-702-0110
Mailing Address - Fax:
Practice Address - Street 1:510 W MAIN ST
Practice Address - Street 2:STE B
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-1454
Practice Address - Country:US
Practice Address - Phone:330-702-0110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT009257225100000X
225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBR4224501Medicare PIN