Provider Demographics
NPI:1003585514
Name:BRANNON, STEPHANIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:BRANNON
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3527 MT DIABLO BLVD # 186
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-3815
Mailing Address - Country:US
Mailing Address - Phone:925-788-0488
Mailing Address - Fax:
Practice Address - Street 1:3480 BUSKIRK AVE STE 150
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4387
Practice Address - Country:US
Practice Address - Phone:925-947-3224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300746225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist