Provider Demographics
NPI:1891426953
Name:AUSTIN, BRANDON LEONE (ATC, LAT, EMT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:LEONE
Last Name:AUSTIN
Suffix:
Gender:M
Credentials:ATC, LAT, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1602
Mailing Address - Country:US
Mailing Address - Phone:203-598-2184
Mailing Address - Fax:
Practice Address - Street 1:1615 STANLEY ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06050-2439
Practice Address - Country:US
Practice Address - Phone:860-832-3086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0016322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer