Provider Demographics
NPI:1881123321
Name:BRADSHAW, CHARLES (PTA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:BRADSHAW
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 1:118 JOHNSON AVE
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:OH
Mailing Address - Zip Code:45822-1219
Mailing Address - Country:US
Mailing Address - Phone:419-953-5367
Mailing Address - Fax:
Practice Address - Street 1:118 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:OH
Practice Address - Zip Code:45822-1219
Practice Address - Country:US
Practice Address - Phone:419-953-5367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA5287225100000X
TX2103110225200000X
ALPTA8365225200000X
OHPTA02163225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist