Provider Demographics
NPI:1710158035
Name:QUEEN, BRANDON (DPT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:QUEEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 N RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60051-5413
Mailing Address - Country:US
Mailing Address - Phone:815-385-0730
Mailing Address - Fax:815-385-0572
Practice Address - Street 1:1783 N RICHMOND RD
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60051-5413
Practice Address - Country:US
Practice Address - Phone:815-385-0730
Practice Address - Fax:815-385-0572
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016276225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist