Healthcare Provider Details

I. General information

NPI: 1235702127
Provider Name (Legal Business Name): BETHANY J BRANDT LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/20/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 W PARK
ASH FORK AZ
86320
US

IV. Provider business mailing address

PO BOX 364
WILLIAMS AZ
86046-0364
US

V. Phone/Fax

Practice location:
  • Phone: 855-277-5901
  • Fax:
Mailing address:
  • Phone: 520-490-7142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-25363
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: