Provider Demographics
NPI:1811553472
Name:BLACKWELL, BRANDON ANTHONY (OTR/L)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:ANTHONY
Last Name:BLACKWELL
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14700 4TH ST APT 216
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-3964
Mailing Address - Country:US
Mailing Address - Phone:216-409-1045
Mailing Address - Fax:
Practice Address - Street 1:1900 L ST NW STE 607
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-5047
Practice Address - Country:US
Practice Address - Phone:202-528-7223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-18
Last Update Date:2019-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08448225X00000X
DC0T010001475225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist