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General NPI Number Information
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NPI Number | 1710754767
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Entity Type | Individual
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Provider Name | BRADLEY EARNEST PT
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Gender | Male
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Dates
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Enumeration Date | 12/11/2023
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Last Update Date | 12/11/2023
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Provider Practice Location Address
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Address Line | 330 RONNELL RD BLDG 300
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City | CANTON
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State | GA
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Zip | 30115-8636
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Country | US
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Telephone | 404-308-0817
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Fax |
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Provider Business Mailing Address
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Address Line | 1773 VISTA TRCE
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City | DECATUR
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State | GA
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Zip | 30033-1143
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Country | US
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Telephone | 404-308-0817
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number | PT015872
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License Number State | GA
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