Healthcare Provider Details

I. General information

NPI: 1952953879
Provider Name (Legal Business Name): BRANDON BISHOP RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 S MAIN ST
LEITCHFIELD KY
42754-1056
US

IV. Provider business mailing address

105 MADELYN DR
LEITCHFIELD KY
42754-3015
US

V. Phone/Fax

Practice location:
  • Phone: 270-352-1133
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-92006
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: