Provider Demographics
NPI:1659043271
Name:MOULDEN, BRADLEY DON (OTR/L)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DON
Last Name:MOULDEN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8203 THORNWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2887
Mailing Address - Country:US
Mailing Address - Phone:502-552-6648
Mailing Address - Fax:
Practice Address - Street 1:8203 THORNWOOD RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2887
Practice Address - Country:US
Practice Address - Phone:502-552-6648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-01
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY132380225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY132380OtherOCCUPATIONAL THERAPIST LICENSE
IN31001444AOtherOCCUPATIONAL THERAPIST LICENSE