Healthcare Provider Details

I. General information

NPI: 1740947704
Provider Name (Legal Business Name): BRANDON ST PETERS DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2021
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3228 N CLARK ST
CHICAGO IL
60657-1602
US

IV. Provider business mailing address

3635 N WILTON AVE APT 2
CHICAGO IL
60613-4575
US

V. Phone/Fax

Practice location:
  • Phone: 773-857-0689
  • Fax:
Mailing address:
  • Phone: 615-478-4575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.026357
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number070.026357
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number070.026357
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: