Provider Demographics
NPI:1881899169
Name:SALVATIERRA, BRANDO Q (PT)
Entity type:Individual
Prefix:MR
First Name:BRANDO
Middle Name:Q
Last Name:SALVATIERRA
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 1:2057 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-3843
Mailing Address - Country:US
Mailing Address - Phone:414-416-6500
Mailing Address - Fax:
Practice Address - Street 1:1700 CA DRIVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:262-898-2804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5336-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40261900Medicaid