Provider Demographics
NPI:1902246382
Name:BRANDT, HARRY FRED JR (CO)
Entity Type:Individual
Prefix:MR
First Name:HARRY
Middle Name:FRED
Last Name:BRANDT
Suffix:JR
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4029 SUNSTONE ST
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6184
Mailing Address - Country:US
Mailing Address - Phone:916-849-7765
Mailing Address - Fax:
Practice Address - Street 1:1648 ELLIS ST
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-8810
Practice Address - Country:US
Practice Address - Phone:406-585-1440
Practice Address - Fax:406-585-1438
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNORT0000000131222Z00000X
MDC12193222Z00000X
CACCS222Z00000X
VACO003610222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA50000OtherCALIFORNIA CHILDREN'S SERVICES (CCS), PANELED PROVIDER FOR ORTHOTICS
VACO003610OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS, PROSTHETICS AND PEDORTHICS
MDC12193OtherBOARD OF CERTIFICATION/ACCREDITATION, INTERNATIONAL
TNORT0000000131OtherLICENCED ORTHOTIST