Provider Demographics
NPI:1174193437
Name:CHAN, BRENDA (DPT, CERT DN)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:DPT, CERT DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 LANIER AVE W STE 303
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7636
Mailing Address - Country:US
Mailing Address - Phone:770-716-8885
Mailing Address - Fax:770-716-7425
Practice Address - Street 1:402 BOMBAY LN
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5826
Practice Address - Country:US
Practice Address - Phone:678-878-2503
Practice Address - Fax:678-878-2505
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist