Provider Demographics
NPI:1578080552
Name:VISSER, BRENNAN EHLINGER (PT, DPT, ATC)
Entity Type:Individual
Prefix:
First Name:BRENNAN
Middle Name:EHLINGER
Last Name:VISSER
Suffix:
Gender:F
Credentials:PT, DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130D SNOW BRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-8411
Mailing Address - Country:US
Mailing Address - Phone:1336-404-1684
Mailing Address - Fax:
Practice Address - Street 1:1130D SNOW BRIDGE LN
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-8411
Practice Address - Country:US
Practice Address - Phone:336-904-0467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist