Provider Demographics
NPI:1336655133
Name:SUTPHIN, BRETT ANDREW (MS, ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:ANDREW
Last Name:SUTPHIN
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BLACKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MURPHYSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62966-2937
Mailing Address - Country:US
Mailing Address - Phone:618-687-2336
Mailing Address - Fax:
Practice Address - Street 1:50 BLACKWOOD DR
Practice Address - Street 2:
Practice Address - City:MURPHYSBORO
Practice Address - State:IL
Practice Address - Zip Code:62966-2937
Practice Address - Country:US
Practice Address - Phone:618-687-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-17
Last Update Date:2017-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960009162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer