Provider Demographics
NPI:1932702651
Name:RICHARDSON, BRANDON (PT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 DEWEY AVE NW STE 300
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5283
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:616-356-5001
Practice Address - Street 1:2080 44TH ST SE STE 150
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-5299
Practice Address - Country:US
Practice Address - Phone:616-233-3590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501019689225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist