Provider Demographics
NPI:1053712166
Name:POWELL, BRADY (PT, DPT)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:
Last Name:POWELL
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 CIVIC CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-6328
Mailing Address - Country:US
Mailing Address - Phone:702-586-5778
Mailing Address - Fax:702-586-5758
Practice Address - Street 1:2225 CIVIC CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-6328
Practice Address - Country:US
Practice Address - Phone:702-586-5778
Practice Address - Fax:702-586-5758
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1207843225100000X
NV30992251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1053712166Medicaid
NVV110594Medicare PIN