Provider Demographics
NPI:1073866638
Name:ELLISON, BRANDON GRAHAM (DPT)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:GRAHAM
Last Name:ELLISON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 MAIDEN CHOICE LN
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-6138
Mailing Address - Country:US
Mailing Address - Phone:410-737-8859
Mailing Address - Fax:410-737-8836
Practice Address - Street 1:719 MAIDEN CHOICE LN
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-6138
Practice Address - Country:US
Practice Address - Phone:410-737-8859
Practice Address - Fax:410-737-8836
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist