Provider Demographics
NPI:1861235293
Name:MCCORMICK, BRANDON (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
Last Name:MCCORMICK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4434 16TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-6995
Mailing Address - Country:US
Mailing Address - Phone:320-808-0159
Mailing Address - Fax:
Practice Address - Street 1:1405 7TH ST S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-3444
Practice Address - Country:US
Practice Address - Phone:218-233-7508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2521225100000X
MN12912225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist