Provider Demographics
NPI:1194192245
Name:HALSTEAD, BRANDON THOMAS (PTA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:THOMAS
Last Name:HALSTEAD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5930 CORNERSTONE CT W STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3772
Mailing Address - Country:US
Mailing Address - Phone:866-687-7390
Mailing Address - Fax:
Practice Address - Street 1:35 BEL AIRE DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-4953
Practice Address - Country:US
Practice Address - Phone:802-334-2878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI004216172V00000X
COPTA.0013570172V00000X
UT9406205-2404172V00000X
OR09204172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker