Healthcare Provider Details

I. General information

NPI: 1962571315
Provider Name (Legal Business Name): BRANDON M TOURTILLOTT PH.D. CCC-A
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 12/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2610 7TH ST
WRIGHT PATTERSON AFB OH
45433-7901
US

IV. Provider business mailing address

2130 CRYSTAL MARIE DR
BEAVERCREEK OH
45431-3314
US

V. Phone/Fax

Practice location:
  • Phone: 937-255-4199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number51590
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: