Provider Demographics
NPI:1861589350
Name:BROUILLETTE, BRADFORD J (PT)
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:J
Last Name:BROUILLETTE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W POPLAR ST.
Mailing Address - Street 2:REHABILITATION SERVICES
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362
Mailing Address - Country:US
Mailing Address - Phone:509-897-3320
Mailing Address - Fax:509-897-5752
Practice Address - Street 1:410 W POPLAR ST.
Practice Address - Street 2:REHABILITATION SERVICES
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362
Practice Address - Country:US
Practice Address - Phone:509-897-3320
Practice Address - Fax:509-897-5752
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008159225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8862028Medicare PIN