Provider Demographics
NPI:1699807636
Name:BRANDT, GILLIAN ELISE (OTR)
Entity Type:Individual
Prefix:MS
First Name:GILLIAN
Middle Name:ELISE
Last Name:BRANDT
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:GILLIAN
Other - Middle Name:ELISE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2301 YALE BLVD SE STE A3
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4350
Mailing Address - Country:US
Mailing Address - Phone:505-385-8028
Mailing Address - Fax:855-254-6287
Practice Address - Street 1:2301 YALE BLVD SE STE A3
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4350
Practice Address - Country:US
Practice Address - Phone:505-385-8028
Practice Address - Fax:855-254-6287
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1964225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM14031078Medicaid