Provider Demographics
NPI:1972375004
Name:BRENNICK, RAYMOND EDWARD III (DPT)
Entity type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:EDWARD
Last Name:BRENNICK
Suffix:III
Gender:M
Credentials:DPT
Other - Prefix:DR
Other - First Name:NED
Other - Middle Name:EDWARD
Other - Last Name:BRENNICK
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:637 MOSS PARK CT
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34743-6130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:637 MOSS PARK CT
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743-6130
Practice Address - Country:US
Practice Address - Phone:407-361-7254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT37249225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty