Provider Demographics
NPI:1104409143
Name:BLACK, BRENDAN ALEXANDER (PT, DPT)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:ALEXANDER
Last Name:BLACK
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 1:1321 SW MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64081-2904
Mailing Address - Country:US
Mailing Address - Phone:816-607-7180
Mailing Address - Fax:
Practice Address - Street 1:1321 SW MARKET ST
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64081-2904
Practice Address - Country:US
Practice Address - Phone:816-607-7180
Practice Address - Fax:816-607-7181
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021023467225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist