Provider Demographics
NPI:1235738188
Name:BACON, BRENDAN WILLIAMS (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:WILLIAMS
Last Name:BACON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 ALBION OVAL
Mailing Address - Street 2:
Mailing Address - City:MAHOPAC
Mailing Address - State:NY
Mailing Address - Zip Code:10541-3600
Mailing Address - Country:US
Mailing Address - Phone:845-264-4953
Mailing Address - Fax:
Practice Address - Street 1:130 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:ARMONK
Practice Address - State:NY
Practice Address - Zip Code:10504-1727
Practice Address - Country:US
Practice Address - Phone:914-273-3413
Practice Address - Fax:914-273-3036
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist