Provider Demographics
NPI:1124039474
Name:LOVELESS, BRANDON (OTR/L , CPED)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:LOVELESS
Suffix:
Gender:M
Credentials:OTR/L , CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 SW 21ST ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73108-1747
Mailing Address - Country:US
Mailing Address - Phone:405-681-4082
Mailing Address - Fax:
Practice Address - Street 1:4400 SW 21ST ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73108-1747
Practice Address - Country:US
Practice Address - Phone:405-681-4082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1228225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
412176589OtherFED TAX ID