Provider Demographics
NPI:1992426738
Name:PENCE, BRADLEY HARRISON (PTA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:HARRISON
Last Name:PENCE
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 1:9611 NEW RD
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:PA
Mailing Address - Zip Code:16428-5721
Mailing Address - Country:US
Mailing Address - Phone:814-897-6687
Mailing Address - Fax:
Practice Address - Street 1:5930 OLD FRENCH RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-3656
Practice Address - Country:US
Practice Address - Phone:814-860-7816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE013171225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant