Healthcare Provider Details

I. General information

NPI: 1790677078
Provider Name (Legal Business Name): ERICA BRADLEY PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2025
Last Update Date: 07/19/2025
Certification Date: 07/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SCHOOL DR
MELBOURNE AR
72556-8620
US

IV. Provider business mailing address

6673 E AR 58 HWY
SIDNEY AR
72577-9179
US

V. Phone/Fax

Practice location:
  • Phone: 870-916-2269
  • Fax:
Mailing address:
  • Phone: 870-509-0828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5031
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: