Provider Demographics
NPI:1689269813
Name:STANTON, BRIAN J (PT, DPT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:STANTON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 LYNDON FARM CT STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5005
Mailing Address - Country:US
Mailing Address - Phone:951-374-7288
Mailing Address - Fax:951-665-5099
Practice Address - Street 1:1005 6TH SOUTH
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-8364
Practice Address - Country:US
Practice Address - Phone:208-587-1777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1343415225100000X
ID1343415225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist