Provider Demographics
NPI:1831458751
Name:CRITCHFIELD, BRENDA JO (MS, ATC, CSCS, LAT)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JO
Last Name:CRITCHFIELD
Suffix:
Gender:F
Credentials:MS, ATC, CSCS, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20329 SKYVIEW DR
Mailing Address - Street 2:UNIT C
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-3559
Mailing Address - Country:US
Mailing Address - Phone:406-431-9628
Mailing Address - Fax:
Practice Address - Street 1:126 MISSOURI AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-8952
Practice Address - Country:US
Practice Address - Phone:573-596-6606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-12
Last Update Date:2012-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20110104892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer