Provider Demographics
NPI:1194434175
Name:FREY, BRANDON (DPT)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:FREY
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 1:2336 ELDEN AVE APT D
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1570
Mailing Address - Country:US
Mailing Address - Phone:714-235-9100
Mailing Address - Fax:
Practice Address - Street 1:22 CORPORATE PLAZA DR STE 113
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7985
Practice Address - Country:US
Practice Address - Phone:949-722-5054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303149225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist