Provider Demographics
NPI:1205926938
Name:BRADLEY, KIRK THOMAS (PT,DPT, MS, ATC)
Entity type:Individual
Prefix:DR
First Name:KIRK
Middle Name:THOMAS
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:PT,DPT, MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13976 E SPARROW HAWK DR
Mailing Address - Street 2:
Mailing Address - City:LOCKEFORD
Mailing Address - State:CA
Mailing Address - Zip Code:95237-9545
Mailing Address - Country:US
Mailing Address - Phone:209-727-5594
Mailing Address - Fax:
Practice Address - Street 1:2105 W MARCH LN STE 3
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6407
Practice Address - Country:US
Practice Address - Phone:209-951-3265
Practice Address - Fax:209-351-3285
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 23700225100000X, 2251E1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0237000Medicaid
CAPT0237000Medicaid