Provider Demographics
NPI:1043853351
Name:EDWARDS, BRADLEY SHANE (COTA)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:SHANE
Last Name:EDWARDS
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 SANDHILL DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-0906
Mailing Address - Country:US
Mailing Address - Phone:252-299-0917
Mailing Address - Fax:
Practice Address - Street 1:3501 SENIOR VILLAGE LN NW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-9618
Practice Address - Country:US
Practice Address - Phone:252-243-3186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12312224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant