Healthcare Provider Details

I. General information

NPI: 1497531768
Provider Name (Legal Business Name): BAILEY BRADISH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2023
Last Update Date: 12/30/2025
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2103 N VETERANS PKWY STE 328
BLOOMINGTON IL
61704-0919
US

IV. Provider business mailing address

2103 N VETERANS PKWY STE 328
BLOOMINGTON IL
61704-0919
US

V. Phone/Fax

Practice location:
  • Phone: 309-948-6469
  • Fax:
Mailing address:
  • Phone: 309-948-6469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160009949
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: