Provider Demographics
NPI:1457750648
Name:TIMMICK, BRENNA K (DPT)
Entity Type:Individual
Prefix:
First Name:BRENNA
Middle Name:K
Last Name:TIMMICK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:BRENNA
Other - Middle Name:K
Other - Last Name:KEANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 WENDELL LN
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:13612-2111
Mailing Address - Country:US
Mailing Address - Phone:610-724-0834
Mailing Address - Fax:
Practice Address - Street 1:25600 NYS ROUTE 342
Practice Address - Street 2:STE. C & D
Practice Address - City:EVANS MILLS
Practice Address - State:NY
Practice Address - Zip Code:13637-3256
Practice Address - Country:US
Practice Address - Phone:315-221-5101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10169225100000X
NY039554-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446631Medicare PIN