Provider Demographics
NPI:1154814267
Name:MCNULTY, BRANDI (MS)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:MCNULTY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12252 LONGVIEW LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34211-4965
Mailing Address - Country:US
Mailing Address - Phone:941-320-3538
Mailing Address - Fax:
Practice Address - Street 1:4630 17TH ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34235-1843
Practice Address - Country:US
Practice Address - Phone:941-487-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist