Healthcare Provider Details

I. General information

NPI: 1932412467
Provider Name (Legal Business Name): M COLLETTE BRANDT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY COLLETTE BRANDT COTA/L, B.S

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4001 FORD RD
PHILADELPHIA PA
19131-2833
US

IV. Provider business mailing address

131 HEDGE LN
COAL TOWNSHIP PA
17866-7719
US

V. Phone/Fax

Practice location:
  • Phone: 215-877-3110
  • Fax: 215-871-3110
Mailing address:
  • Phone: 570-975-9434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOP001163L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: