=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831446202
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIANNA M BRANDON L.M.T
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2012
-----------------------------------------------------
Last Update Date | 08/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 363 W MAIN ST
-----------------------------------------------------
City | LEWISVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75057-3867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-368-3203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5531 MANITOU DR
-----------------------------------------------------
City | PROSPER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75078-5641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-368-3203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT113632
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------