Provider Demographics
NPI:1144812223
Name:TREAN, BRANDON (BCTMB)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:TREAN
Suffix:
Gender:M
Credentials:BCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2144 S DOROTHY AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4410
Mailing Address - Country:US
Mailing Address - Phone:208-870-9753
Mailing Address - Fax:
Practice Address - Street 1:760 E WARM SPRINGS AVE STE A
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6459
Practice Address - Country:US
Practice Address - Phone:208-870-9753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1124225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist