Healthcare Provider Details

I. General information

NPI: 1215519632
Provider Name (Legal Business Name): BRANDI G SPENCER HAIR LOSS SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRANDI G SPENCER CERTIFIED HAIR LOSS

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 S EAST ST STE 107
INDIANAPOLIS IN
46227-2076
US

IV. Provider business mailing address

5401 S EAST ST STE 107
INDIANAPOLIS IN
46227-2076
US

V. Phone/Fax

Practice location:
  • Phone: 463-224-7952
  • Fax:
Mailing address:
  • Phone: 463-224-7952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberBC21300617
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: