Provider Demographics
NPI:1770966947
Name:RANDLEMAN, BRENDA JO (PTA)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:JO
Last Name:RANDLEMAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 HAMILTON CT
Mailing Address - Street 2:
Mailing Address - City:RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54022-3126
Mailing Address - Country:US
Mailing Address - Phone:715-425-7388
Mailing Address - Fax:
Practice Address - Street 1:2305 WILLIS MILLER DR
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-7999
Practice Address - Country:US
Practice Address - Phone:715-386-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2129-19225200000X
MNA1505225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant