Provider Demographics
NPI:1124632252
Name:VANDEKERCKHOVE, BRENNAN (LMT)
Entity type:Individual
Prefix:
First Name:BRENNAN
Middle Name:
Last Name:VANDEKERCKHOVE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:787 LOCKLEAR AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-8317
Mailing Address - Country:US
Mailing Address - Phone:248-520-7237
Mailing Address - Fax:
Practice Address - Street 1:1967 MORRILL ST REAR STUDIO
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-6934
Practice Address - Country:US
Practice Address - Phone:248-520-7237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-05
Last Update Date:2020-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA89095225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist