Provider Demographics
NPI:1164077731
Name:BACK, BRITTANY BIANCA (DPT)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:BIANCA
Last Name:BACK
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 1:2689 BRADEN WAY APT 44-2689
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-8571
Mailing Address - Country:US
Mailing Address - Phone:606-276-7685
Mailing Address - Fax:
Practice Address - Street 1:2531 OLD ROSEBUD RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-4574
Practice Address - Country:US
Practice Address - Phone:859-554-1619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007704225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKYHAN5746431OtherANTHEM BLUECROSS BLUESHIELD