Healthcare Provider Details

I. General information

NPI: 1134730153
Provider Name (Legal Business Name): BRANDON CORY VANDERBROOK CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 S LINCOLN AVE
LEBANON PA
17042-7529
US

IV. Provider business mailing address

363 TOWNHOUSE
HERSHEY PA
17033-2385
US

V. Phone/Fax

Practice location:
  • Phone: 717-272-6621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number69938
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: