Provider Demographics
NPI:1902459613
Name:RUSSELL, BRADLEY (DPT)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 E VERONA AVE
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593-1227
Mailing Address - Country:US
Mailing Address - Phone:608-848-6628
Mailing Address - Fax:608-848-6629
Practice Address - Street 1:416 E VERONA AVE
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-1227
Practice Address - Country:US
Practice Address - Phone:608-848-6628
Practice Address - Fax:608-848-6629
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14739-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist