Provider Demographics
NPI:1356670129
Name:BRANTLEY, KEITH (PT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:BRANTLEY
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:648 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-4646
Mailing Address - Country:US
Mailing Address - Phone:716-570-9757
Mailing Address - Fax:716-694-4090
Practice Address - Street 1:4635 UNION RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-1851
Practice Address - Country:US
Practice Address - Phone:716-505-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist