Provider Demographics
NPI:1992963888
Name:WHETTEN, BRADY K (PT, DPT, GCS)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:K
Last Name:WHETTEN
Suffix:
Gender:M
Credentials:PT, DPT, GCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3270 LIBERTY RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-371-0779
Mailing Address - Fax:503-371-0886
Practice Address - Street 1:3270 LIBERTY RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-371-0779
Practice Address - Fax:503-371-0886
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5636225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR245938Medicaid
OR245938Medicaid