Provider Demographics
NPI:1154914984
Name:BETTIN, BRENNEN HOWARD (PT)
Entity type:Individual
Prefix:
First Name:BRENNEN
Middle Name:HOWARD
Last Name:BETTIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 WHITE PINE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-8131
Mailing Address - Country:US
Mailing Address - Phone:760-547-3031
Mailing Address - Fax:
Practice Address - Street 1:101 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-8301
Practice Address - Country:US
Practice Address - Phone:760-547-3031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT36978225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist