Provider Demographics
NPI:1619478039
Name:PETERSON, BRANDIE (MS, ATC, CES, PES)
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:MS, ATC, CES, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:565 SPARKS BLVD
Mailing Address - Street 2:870
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89434
Mailing Address - Country:US
Mailing Address - Phone:775-636-4342
Mailing Address - Fax:
Practice Address - Street 1:820 15TH ST
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-0939
Practice Address - Country:US
Practice Address - Phone:775-636-4342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05062292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer