=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710871785
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENNAN SPEZIA DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2025
-----------------------------------------------------
Last Update Date | 07/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3460 BATTLEFIELD PKWY
-----------------------------------------------------
City | FORT OGLETHORPE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30742-4007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-719-2253
-----------------------------------------------------
Fax | 800-385-7439
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 KENMOOR AVE SE STE 100
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-2395
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 16377
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | CP045036T
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------