Provider Demographics
NPI:1124366158
Name:SPECKHALS, BRANDEN
Entity Type:Individual
Prefix:
First Name:BRANDEN
Middle Name:
Last Name:SPECKHALS
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 1:2347 HIGHWAY 100
Mailing Address - Street 2:
Mailing Address - City:HERMANN
Mailing Address - State:MO
Mailing Address - Zip Code:65041-4226
Mailing Address - Country:US
Mailing Address - Phone:573-690-8862
Mailing Address - Fax:
Practice Address - Street 1:2347 HIGHWAY 100
Practice Address - Street 2:
Practice Address - City:HERMANN
Practice Address - State:MO
Practice Address - Zip Code:65041-4226
Practice Address - Country:US
Practice Address - Phone:573-690-8862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012038625225200000X
TX2094108225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant