Provider Demographics
NPI:1215393913
Name:BRANDON, LEA (LMT)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:BRANDON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8012 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:GOODRICH
Mailing Address - State:MI
Mailing Address - Zip Code:48438-9206
Mailing Address - Country:US
Mailing Address - Phone:810-252-7688
Mailing Address - Fax:
Practice Address - Street 1:8555 MONROE RD
Practice Address - Street 2:
Practice Address - City:DURAND
Practice Address - State:MI
Practice Address - Zip Code:48429-1036
Practice Address - Country:US
Practice Address - Phone:517-214-5435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-11
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501003521225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist