Provider Demographics
NPI:1689250383
Name:BRANDENBURG, MATTHEW COLE (OTD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:COLE
Last Name:BRANDENBURG
Suffix:
Gender:M
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13535 KNOTTY LOG CT
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-2406
Mailing Address - Country:US
Mailing Address - Phone:703-939-7988
Mailing Address - Fax:
Practice Address - Street 1:2012 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3151
Practice Address - Country:US
Practice Address - Phone:702-360-1137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist