Provider Demographics
NPI:1902906035
Name:BRABANT, LINDA L (PT)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:L
Last Name:BRABANT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 E CEDAR AVE STE E-2
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1646
Mailing Address - Country:US
Mailing Address - Phone:928-214-7430
Mailing Address - Fax:928-214-6022
Practice Address - Street 1:1515 E CEDAR AVE STE E-2
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1646
Practice Address - Country:US
Practice Address - Phone:928-214-7430
Practice Address - Fax:928-214-6022
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5592225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ633992Medicaid
AZ633992Medicaid