Provider Demographics
NPI:1871833509
Name:LOCKHART, JUSTIN BRADLEY (PTA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BRADLEY
Last Name:LOCKHART
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-2365
Mailing Address - Country:US
Mailing Address - Phone:574-208-7541
Mailing Address - Fax:
Practice Address - Street 1:303 N HURSTBOURNE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5158
Practice Address - Country:US
Practice Address - Phone:502-412-5847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-16
Last Update Date:2013-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004561A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant