Provider Demographics
NPI:1134963218
Name:BRANTLEY, PORTIA (LMT)
Entity type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:COACH PORTIA
Other - Middle Name:
Other - Last Name:BRANTLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ICF PCC
Mailing Address - Street 1:270 PLATT ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-2945
Mailing Address - Country:US
Mailing Address - Phone:203-727-5368
Mailing Address - Fax:
Practice Address - Street 1:1000 LAFAYETTE BLVD # 1107
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-4725
Practice Address - Country:US
Practice Address - Phone:203-727-5368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11341225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist