Provider Demographics
NPI:1578819421
Name:STREET, BRIAN (PT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:STREET
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 1:15 DORIS CT SE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-3823
Mailing Address - Country:US
Mailing Address - Phone:864-804-3270
Mailing Address - Fax:
Practice Address - Street 1:15 DORIS CT SE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3823
Practice Address - Country:US
Practice Address - Phone:864-804-3270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13701225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist