Provider Demographics
NPI:1497386650
Name:BRANDENBURG, HEATHER (PT, DPT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:BRANDENBURG
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 1:7970 RAVEN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE TOMAHAWK
Mailing Address - State:WI
Mailing Address - Zip Code:54539-9588
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 LEE AVE UNIT 103
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-2149
Practice Address - Country:US
Practice Address - Phone:302-500-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14827-24225100000X
COPTL.0016499225100000X
DEJ1-0004186225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist