Provider Demographics
NPI:1295450674
Name:BRANTLEY, CASSIDY-RAE
Entity type:Individual
Prefix:
First Name:CASSIDY-RAE
Middle Name:
Last Name:BRANTLEY
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 1:2375 SW 30TH TER
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-4368
Mailing Address - Country:US
Mailing Address - Phone:954-809-5916
Mailing Address - Fax:
Practice Address - Street 1:301 CAMINO GARDENS BLVD UNIT 100
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-5823
Practice Address - Country:US
Practice Address - Phone:561-494-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23553225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist