Healthcare Provider Details

I. General information

NPI: 1003306697
Provider Name (Legal Business Name): BRANDON DALE PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 APPLEWOOD DR
ONA WV
25545-9581
US

IV. Provider business mailing address

2523 YATES CROSSING RD
MILTON WV
25541-8509
US

V. Phone/Fax

Practice location:
  • Phone: 276-970-6076
  • Fax:
Mailing address:
  • Phone: 276-970-6076
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT003963
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: