Provider Demographics
NPI:1164452231
Name:STAUTH, BRENT (PT)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:STAUTH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6727 EVERGLADES CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-3920
Mailing Address - Country:US
Mailing Address - Phone:480-603-7650
Mailing Address - Fax:
Practice Address - Street 1:6727 EVERGLADES CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-3920
Practice Address - Country:US
Practice Address - Phone:480-603-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05014664A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist