Provider Demographics
NPI:1932412467
Name:BRANDT, M COLLETTE
Entity Type:Individual
Prefix:
First Name:M COLLETTE
Middle Name:
Last Name:BRANDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:COLLETTE
Other - Last Name:BRANDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:COTA/L, BS
Mailing Address - Street 1:131 HEDGE LN
Mailing Address - Street 2:
Mailing Address - City:COAL TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:17866-7719
Mailing Address - Country:US
Mailing Address - Phone:570-975-9434
Mailing Address - Fax:
Practice Address - Street 1:4001 FORD RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-2833
Practice Address - Country:US
Practice Address - Phone:215-877-3110
Practice Address - Fax:215-871-3110
Is Sole Proprietor?:No
Enumeration Date:2010-07-26
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP001163L224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1932412467OtherCOTA/L