Provider Demographics
NPI:1477898427
Name:CARSON, BRANDI LYNN (PTA)
Entity Type:Individual
Prefix:MS
First Name:BRANDI
Middle Name:LYNN
Last Name:CARSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:LYNN
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:1809 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-3111
Mailing Address - Country:US
Mailing Address - Phone:414-507-3275
Mailing Address - Fax:
Practice Address - Street 1:1809 S 17TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3111
Practice Address - Country:US
Practice Address - Phone:414-507-3275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI97019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant