Provider Demographics
NPI:1790913101
Name:PHILLIPS, BRANDON MICHAEL
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:MICHAEL
Last Name:PHILLIPS
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 1:3711 N ROAN ST
Mailing Address - Street 2:APT B14
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601
Mailing Address - Country:US
Mailing Address - Phone:423-213-7099
Mailing Address - Fax:
Practice Address - Street 1:3711 N ROAN ST
Practice Address - Street 2:APT B14
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1258
Practice Address - Country:US
Practice Address - Phone:423-213-7099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446506Medicare UPIN