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General NPI Number Information
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NPI Number | 1568139640
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Entity Type | Individual
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Provider Name | BRANDON MATTHEW TODD DPT
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Gender | Male
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Dates
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Enumeration Date | 08/25/2021
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Last Update Date | 08/25/2021
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Provider Practice Location Address
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Address Line | 1912 W POTTER DR APT A
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City | BOISE
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State | ID
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Zip | 83706-3149
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Country | US
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Telephone | 425-231-9017
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Fax |
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Provider Business Mailing Address
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Address Line | 3208 132ND AVE SE
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City | SNOHOMISH
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State | WA
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Zip | 98290-9743
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT-7520
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License Number State | ID
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