Provider Demographics
NPI:1558647420
Name:SPACK, BRANDON (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:SPACK
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 CHASE COURT
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032
Mailing Address - Country:US
Mailing Address - Phone:317-848-5867
Mailing Address - Fax:
Practice Address - Street 1:1402 CHASE COURT
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032
Practice Address - Country:US
Practice Address - Phone:317-848-5867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001762A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer