Provider Demographics
NPI:1003385634
Name:TANNER, BRENDAN CLARK (PT, DPT, NCS)
Entity Type:Individual
Prefix:DR
First Name:BRENDAN
Middle Name:CLARK
Last Name:TANNER
Suffix:
Gender:M
Credentials:PT, DPT, NCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3145 WALTER AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63143-3913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3145 WALTER AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MO
Practice Address - Zip Code:63143-3913
Practice Address - Country:US
Practice Address - Phone:314-607-6384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002027897225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist