Provider Demographics
NPI:1811193659
Name:BRABHAM, ROBERT WILEY II (PTA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WILEY
Last Name:BRABHAM
Suffix:II
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:NC
Mailing Address - Zip Code:28034-9357
Mailing Address - Country:US
Mailing Address - Phone:704-923-0071
Mailing Address - Fax:
Practice Address - Street 1:2300 ABERDEEN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0613
Practice Address - Country:US
Practice Address - Phone:704-834-3037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2997225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant