Provider Demographics
NPI:1235702127
Name:BRANDT, BETHANY J (LMT)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:J
Last Name:BRANDT
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:PO BOX 364
Mailing Address - Street 2:
Mailing Address - City:WILLIAMS
Mailing Address - State:AZ
Mailing Address - Zip Code:86046-0364
Mailing Address - Country:US
Mailing Address - Phone:520-490-7142
Mailing Address - Fax:
Practice Address - Street 1:112 W PARK
Practice Address - Street 2:
Practice Address - City:ASH FORK
Practice Address - State:AZ
Practice Address - Zip Code:86320
Practice Address - Country:US
Practice Address - Phone:855-277-5901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-25363225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist