Provider Demographics
NPI:1871824466
Name:DETAR, BRANDIE
Entity Type:Individual
Prefix:
First Name:BRANDIE
Middle Name:
Last Name:DETAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18200 YORBA LINDA BLVD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-4056
Mailing Address - Country:US
Mailing Address - Phone:714-646-8000
Mailing Address - Fax:714-572-2562
Practice Address - Street 1:18200 YORBA LINDA BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-4056
Practice Address - Country:US
Practice Address - Phone:714-646-8000
Practice Address - Fax:714-572-2562
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1237678225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1237678OtherMASSAGE THERAPY ASSOCIATION LICENSE