Provider Demographics
NPI:1043645880
Name:BRADT, ELIZABETH A (PT)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:A
Last Name:BRADT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:A
Other - Last Name:BEIGHLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1415 GREEN DR
Mailing Address - Street 2:
Mailing Address - City:HAZEL GREEN
Mailing Address - State:WI
Mailing Address - Zip Code:53811-9549
Mailing Address - Country:US
Mailing Address - Phone:734-755-0139
Mailing Address - Fax:
Practice Address - Street 1:1415 GREEN DR
Practice Address - Street 2:
Practice Address - City:HAZEL GREEN
Practice Address - State:WI
Practice Address - Zip Code:53811-9549
Practice Address - Country:US
Practice Address - Phone:734-755-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT011233225100000X
WI12902225100000X
MN9808225100000X
IA005186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
202I657447Medicare UPIN