Provider Demographics
NPI:1346599974
Name:BRANDOW, CARLA DAWN (MMT)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:DAWN
Last Name:BRANDOW
Suffix:
Gender:F
Credentials:MMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E TOWNSHIP ST STE 5
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2896
Mailing Address - Country:US
Mailing Address - Phone:479-521-9119
Mailing Address - Fax:
Practice Address - Street 1:125 E TOWNSHIP ST STE 5
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2896
Practice Address - Country:US
Practice Address - Phone:479-521-9119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3373225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist