Provider Demographics
NPI:1497050983
Name:RILLAHAN, BRENDEN J (PT)
Entity Type:Individual
Prefix:
First Name:BRENDEN
Middle Name:J
Last Name:RILLAHAN
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 1:100 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-2000
Mailing Address - Fax:518-926-2020
Practice Address - Street 1:17 MAIN ST
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-4007
Practice Address - Country:US
Practice Address - Phone:518-926-2040
Practice Address - Fax:518-798-0815
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017195-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist