Provider Demographics
NPI:1669851895
Name:STAUBLE, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:STAUBLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10330 BUNSEN WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-2508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10330 BUNSEN WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299
Practice Address - Country:US
Practice Address - Phone:502-495-1662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA03142225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant