Provider Demographics
NPI:1912976853
Name:DEDERICH, BRANDON (MPT, MS, ATC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:DEDERICH
Suffix:
Gender:M
Credentials:MPT, MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 W LOS ANGELES AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-4218
Mailing Address - Country:US
Mailing Address - Phone:805-552-1915
Mailing Address - Fax:805-552-1991
Practice Address - Street 1:144 W LOS ANGELES AVE STE 110
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-4218
Practice Address - Country:US
Practice Address - Phone:805-552-1915
Practice Address - Fax:805-552-1991
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26864225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA264440100OtherDEPT OF LABOR
CAOPT268640OtherBLUE SHIELD INDIVIDUAL
CAZZZ082282OtherBLUE SHIELD GROUP#
CA264440100OtherDEPT OF LABOR
CAW17334Medicare ID - Type UnspecifiedGROUP MEDICARE