Provider Demographics
NPI:1114078946
Name:MADSEN, BRENDA (DPT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:MADSEN
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 1:20301 BLUFFSIDE CIR
Mailing Address - Street 2:#113
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-8521
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18102 IRVINE BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3402
Practice Address - Country:US
Practice Address - Phone:714-505-2966
Practice Address - Fax:714-505-2976
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT244472251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic