Provider Demographics
NPI:1356113286
Name:DAVIS, BRENDA MICHELE (LPTA)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:MICHELE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 MOLINO RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-6246
Mailing Address - Country:US
Mailing Address - Phone:205-936-2923
Mailing Address - Fax:
Practice Address - Street 1:4081 THORNTON TAYLOR PKWY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-2674
Practice Address - Country:US
Practice Address - Phone:931-433-9973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-24
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN8354225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant