Provider Demographics
NPI:1174246227
Name:BRANDT, BAILEY
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:
Last Name:BRANDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 W GREENLEAF AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-2419
Mailing Address - Country:US
Mailing Address - Phone:872-240-0668
Mailing Address - Fax:
Practice Address - Street 1:6820 MADRONE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9578
Practice Address - Country:US
Practice Address - Phone:480-313-6777
Practice Address - Fax:855-810-1930
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist