Provider Demographics
NPI:1861845232
Name:BRANDT, TANYA (PTA)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:BRANDT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:201 TAHOMA BLVD
Practice Address - Street 2:SUITE 207
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-7735
Practice Address - Country:US
Practice Address - Phone:360-458-6400
Practice Address - Fax:360-458-6444
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP1 60589729225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant