Provider Demographics
NPI:1033139274
Name:RICHARDSON, BRENDA ELAINE (PT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:ELAINE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3160 W BRITTON RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-2039
Mailing Address - Country:US
Mailing Address - Phone:405-751-9595
Mailing Address - Fax:405-755-4045
Practice Address - Street 1:3160 W BRITTON RD
Practice Address - Street 2:SUITE C
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-2068
Practice Address - Country:US
Practice Address - Phone:405-751-9595
Practice Address - Fax:405-755-4045
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT1362225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1194847988OtherGROUP NPI
OK731367002OtherEIN
OK1194847988OtherGROUP NPI