Provider Demographics
NPI:1548330483
Name:BRADY, GERALD THOMAS (DC)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:THOMAS
Last Name:BRADY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65111
Mailing Address - Street 2:119 VILLAGE WAY
Mailing Address - City:PORT LUDLOW
Mailing Address - State:WA
Mailing Address - Zip Code:98365-0111
Mailing Address - Country:US
Mailing Address - Phone:360-437-8008
Mailing Address - Fax:360-437-0406
Practice Address - Street 1:119 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:PORT LUDLOW
Practice Address - State:WA
Practice Address - Zip Code:98365-8792
Practice Address - Country:US
Practice Address - Phone:360-437-8008
Practice Address - Fax:360-437-0406
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002344111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8851795Medicare ID - Type Unspecified