Provider Demographics
NPI:1376958538
Name:MYCZKOWSKI, BRITTANY B (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRITTANY
Middle Name:B
Last Name:MYCZKOWSKI
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 681478
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-1478
Mailing Address - Country:US
Mailing Address - Phone:615-591-6590
Mailing Address - Fax:615-591-6601
Practice Address - Street 1:2182 GALLATIN PIKE N
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-2004
Practice Address - Country:US
Practice Address - Phone:615-859-7775
Practice Address - Fax:615-859-7772
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10212225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05954OtherGROUP MEDICARE PTAN
VA1376958538OtherMEDICAID QMB ONLY INDIVIDUAL PROVIDER ID
VAQ47241AMedicare PIN
VA1376958538OtherMEDICAID QMB ONLY INDIVIDUAL PROVIDER ID