Provider Demographics
NPI:1639569627
Name:GANZ, BRENDA (PTA)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:GANZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 70022
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-0019
Mailing Address - Country:US
Mailing Address - Phone:843-283-0644
Mailing Address - Fax:
Practice Address - Street 1:7509 N OCEAN BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4246
Practice Address - Country:US
Practice Address - Phone:843-283-0644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2610225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant