Provider Demographics
NPI:1437689627
Name:RETALLACK, BRANDY M (LMT, DOULA)
Entity Type:Individual
Prefix:MRS
First Name:BRANDY
Middle Name:M
Last Name:RETALLACK
Suffix:
Gender:F
Credentials:LMT, DOULA
Other - Prefix:
Other - First Name:BRANDY
Other - Middle Name:M
Other - Last Name:ZAGORSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22 N PHILADELPHIA BLVD
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MD
Mailing Address - Zip Code:21001-2511
Mailing Address - Country:US
Mailing Address - Phone:443-617-6607
Mailing Address - Fax:
Practice Address - Street 1:22 N PHILADELPHIA BLVD
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21001-2511
Practice Address - Country:US
Practice Address - Phone:443-617-6607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374J00000X
MDM05698225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist