Healthcare Provider Details

I. General information

NPI: 1417573403
Provider Name (Legal Business Name): BRANDON HENRY LY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 LOMBARD ST
PHILADELPHIA PA
19146-1625
US

IV. Provider business mailing address

1526 LOMBARD ST
PHILADELPHIA PA
19146-1625
US

V. Phone/Fax

Practice location:
  • Phone: 215-546-5960
  • Fax:
Mailing address:
  • Phone: 215-546-5960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL013102
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: