Provider Demographics
NPI:1285661850
Name:TAYLOR, BRENDA (PT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9538 E IDAHO AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-4691
Mailing Address - Country:US
Mailing Address - Phone:720-254-7363
Mailing Address - Fax:
Practice Address - Street 1:1025 EAST BROADWAY SUITE 101
Practice Address - Street 2:TEMPE SPORTS CLINIC
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282
Practice Address - Country:US
Practice Address - Phone:480-829-0217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5078225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA108927Medicare PIN
COC805017Medicare PIN