Provider Demographics
NPI:1992717326
Name:BRADY, ELS P (PT)
Entity type:Individual
Prefix:
First Name:ELS
Middle Name:P
Last Name:BRADY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0708
Mailing Address - Country:US
Mailing Address - Phone:907-441-6986
Mailing Address - Fax:
Practice Address - Street 1:2302 N BOGUS BASIN RD STE C
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-1024
Practice Address - Country:US
Practice Address - Phone:208-344-0737
Practice Address - Fax:208-344-0759
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA546225100000X
IDPT-6648225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKPT9195Medicaid
AKK150572Medicare PIN