Provider Demographics
NPI:1275416570
Name:WATHEN, BRADLEY (LMT)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:WATHEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5030 LAIPO ROAD
Mailing Address - Street 2:#B
Mailing Address - City:KAPAA
Mailing Address - State:HI
Mailing Address - Zip Code:96746
Mailing Address - Country:US
Mailing Address - Phone:530-559-1664
Mailing Address - Fax:
Practice Address - Street 1:4-356 KUHIO HIGHWAY
Practice Address - Street 2:#113B
Practice Address - City:KAPAA
Practice Address - State:HI
Practice Address - Zip Code:96746
Practice Address - Country:US
Practice Address - Phone:530-559-1664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-26
Last Update Date:2025-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT-18005225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist