Provider Demographics
NPI:1336637479
Name:LILES, BRANDI (LPTA)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:LILES
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10481 KEYSBURG CT
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-7785
Mailing Address - Country:US
Mailing Address - Phone:318-518-9696
Mailing Address - Fax:
Practice Address - Street 1:10481 KEYSBURG CT
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-7785
Practice Address - Country:US
Practice Address - Phone:318-518-9696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2044154225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant