Provider Demographics
NPI:1497899900
Name:BRANDON, LUCILLE MCMANIS (PT)
Entity Type:Individual
Prefix:MRS
First Name:LUCILLE
Middle Name:MCMANIS
Last Name:BRANDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:LUCILLE
Other - Middle Name:MCMANIS
Other - Last Name:HICKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4610 CHUCK DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-2615
Mailing Address - Country:US
Mailing Address - Phone:940-691-6188
Mailing Address - Fax:940-691-6188
Practice Address - Street 1:4610 CHUCK DR
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76310-2615
Practice Address - Country:US
Practice Address - Phone:940-691-6188
Practice Address - Fax:940-691-6188
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1019909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist