Basic Information
| Provider Information | |||||||||
| NPI: | 1821428731 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARLEY | ||||||||
| FirstName: | BRANDY | ||||||||
| MiddleName: | JENNIFER | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3441 HOLLAND CLIFFS RD | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206399721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3013994471 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11325 PEMBROOKE SQ | ||||||||
| Address2: | SUITE #115 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206034807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017191167 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2013 | ||||||||
| LastUpdateDate: | 11/14/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A2949 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.