Provider Demographics
NPI:1720167752
Name:BLISS, BRANDON KENNETH (DPT)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:KENNETH
Last Name:BLISS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0307
Mailing Address - Country:US
Mailing Address - Phone:888-700-6907
Mailing Address - Fax:801-294-6917
Practice Address - Street 1:3303 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4438
Practice Address - Country:US
Practice Address - Phone:801-373-7438
Practice Address - Fax:801-373-7486
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3085245-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist