Basic Information
| Provider Information | |||||||||
| NPI: | 1700356417 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRANT AUDIOLOGY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 21804 | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820037073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0742643273 | ||||||||
| FaxNumber: | 3074263277 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 W 22ND AVE | ||||||||
| Address2: | |||||||||
| City: | TORRINGTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 822402301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072351901 | ||||||||
| FaxNumber: | 3074264327 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2018 | ||||||||
| LastUpdateDate: | 11/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTENSEN | ||||||||
| AuthorizedOfficialFirstName: | BRANT | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3074264327 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BRANT AUDIOLOGY, LLC | ||||||||
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| AuthorizedOfficialCredential: | AU.D. | ||||||||
| NPICertificationDate: | 11/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231HA2400X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist | Assistive Technology Practitioner | 2355A2700X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Specialist/Technologist | Audiology Assistant | 237600000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist | 231H00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 143657100 | 05 | WY | MEDICAID |