Provider Demographics
NPI:1104109503
Name:BRASCH, DANIEL (DPT)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:BRASCH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:702 SW RAMSEY AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5858
Practice Address - Country:US
Practice Address - Phone:541-479-0765
Practice Address - Fax:541-479-3461
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6590225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP01021707OtherRR MEDICARE
OR500639148Medicaid
WAR161728Medicare PIN