Provider Demographics
NPI:1912194812
Name:BRANNON, DOROTHY
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:BRANNON
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 1:334 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29803-7520
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:690 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6348
Practice Address - Country:US
Practice Address - Phone:803-648-8344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC744225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ351589262Medicare UPIN