Provider Demographics
NPI:1669793600
Name:HEIDAKER, BRANDON JACOB (PT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JACOB
Last Name:HEIDAKER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 E SAM HOUSTON PKWY S
Mailing Address - Street 2:SUITE 215
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77505-3959
Mailing Address - Country:US
Mailing Address - Phone:281-487-2786
Mailing Address - Fax:281-487-3054
Practice Address - Street 1:4500 E SAM HOUSTON PKWY S
Practice Address - Street 2:SUITE 215
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-3959
Practice Address - Country:US
Practice Address - Phone:281-487-2786
Practice Address - Fax:281-487-3054
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1197246225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist