Provider Demographics
NPI:1700597861
Name:SIMON, BRANDON TODD (DPT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:TODD
Last Name:SIMON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1410
Mailing Address - Street 2:
Mailing Address - City:SCOTT
Mailing Address - State:LA
Mailing Address - Zip Code:70583-1410
Mailing Address - Country:US
Mailing Address - Phone:337-703-3274
Mailing Address - Fax:337-981-9182
Practice Address - Street 1:2115 DULLES DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-2652
Practice Address - Country:US
Practice Address - Phone:337-981-9182
Practice Address - Fax:337-988-3441
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2022-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA11400OtherPT LICENSE