Provider Demographics
NPI:1619548724
Name:MARTINDALE, BRIANNA RENE (CTRS)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:RENE
Last Name:MARTINDALE
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:RENE
Other - Last Name:GROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:607 BUFFALO PASS
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-6511
Mailing Address - Country:US
Mailing Address - Phone:512-217-4848
Mailing Address - Fax:
Practice Address - Street 1:1601 COUNTY ROAD 107
Practice Address - Street 2:
Practice Address - City:HUTTO
Practice Address - State:TX
Practice Address - Zip Code:78634-3009
Practice Address - Country:US
Practice Address - Phone:254-987-0405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX58066225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX58066OtherCOUNCIL FOR THERAPEUTIC RECREATION CERTIFICATION