Provider Demographics
NPI:1902985468
Name:BRADLEY, ALICIA RAE (PT)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:RAE
Last Name:BRADLEY
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 1:5900 N BURDICK ST
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9462
Mailing Address - Country:US
Mailing Address - Phone:315-656-4217
Mailing Address - Fax:315-656-4619
Practice Address - Street 1:5900 N BURDICK ST
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9462
Practice Address - Country:US
Practice Address - Phone:315-656-4217
Practice Address - Fax:315-656-4619
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027870-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RB7903Medicare PIN