Provider Demographics
NPI:1114397312
Name:BRANDT, BENJAMIN TYLER
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:TYLER
Last Name:BRANDT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:HARRAH
Mailing Address - State:OK
Mailing Address - Zip Code:73045-0746
Mailing Address - Country:US
Mailing Address - Phone:405-454-0010
Mailing Address - Fax:405-454-0030
Practice Address - Street 1:19629 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:HARRAH
Practice Address - State:OK
Practice Address - Zip Code:73045-9305
Practice Address - Country:US
Practice Address - Phone:405-454-0010
Practice Address - Fax:405-454-0030
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015225100000X
OK5233225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist