Provider Demographics
NPI:1336869742
Name:DEROUCHIE, BRANDON EDWARD (DPT)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:EDWARD
Last Name:DEROUCHIE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:25241 ELEMENTARY WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-7883
Mailing Address - Country:US
Mailing Address - Phone:239-947-4184
Mailing Address - Fax:239-947-4171
Practice Address - Street 1:17751 MURDOCK CIR
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1034
Practice Address - Country:US
Practice Address - Phone:941-743-8700
Practice Address - Fax:941-743-8850
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT41183225100000X
NY049257-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist