Healthcare Provider Details

I. General information

NPI: 1417413246
Provider Name (Legal Business Name): DEREK BRADY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 S MAIN ST
CLARKSTON MI
48346-1526
US

IV. Provider business mailing address

1773 STAR BATT DR
ROCHESTER HILLS MI
48309-3708
US

V. Phone/Fax

Practice location:
  • Phone: 248-922-9001
  • Fax:
Mailing address:
  • Phone: 248-601-9207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501019081
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: