Provider Demographics
NPI:1093086845
Name:CHILDS, BRANDI DIANE (DPT)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:DIANE
Last Name:CHILDS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4079 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5633
Mailing Address - Country:US
Mailing Address - Phone:718-984-8400
Mailing Address - Fax:718-984-8419
Practice Address - Street 1:4079 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5633
Practice Address - Country:US
Practice Address - Phone:718-984-8400
Practice Address - Fax:718-984-8419
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034608-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist