Provider Demographics
NPI:1033579966
Name:DECKER, BRANDY (PTA)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:DECKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 E LOVE ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-2912
Mailing Address - Country:US
Mailing Address - Phone:573-258-9050
Mailing Address - Fax:
Practice Address - Street 1:419 HARDING ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NM
Practice Address - Zip Code:88415-3323
Practice Address - Country:US
Practice Address - Phone:575-374-2562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-04
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015036824225200000X
NMA-1210225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant