Healthcare Provider Details

I. General information

NPI: 1508471145
Provider Name (Legal Business Name): MICHAEL CLELLAND BRENTS PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2020
Last Update Date: 09/10/2020
Certification Date: 09/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 W 1ST ST STE 103
CAMPBELLSVILLE KY
42718-2264
US

IV. Provider business mailing address

7202 WILLIAMSGATE BLVD
CRESTWOOD KY
40014-7017
US

V. Phone/Fax

Practice location:
  • Phone: 270-789-6629
  • Fax:
Mailing address:
  • Phone: 502-689-6557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number005671
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: