Provider Demographics
NPI:1033303862
Name:BRADLEY, DOUGLAS (PT, CSCS)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 BUTTERFIELD RD STE 1600
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:313 N WEBER RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-1569
Practice Address - Country:US
Practice Address - Phone:630-771-0850
Practice Address - Fax:630-771-0852
Is Sole Proprietor?:No
Enumeration Date:2007-09-05
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05007954A225100000X
IL070009229225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7454077OtherAETNA
01622333OtherBLUE CROSS BLUE SHIELD ID