Provider Demographics
NPI:1215234372
Name:LANDRUM, BRENNA CLARK (PT)
Entity type:Individual
Prefix:
First Name:BRENNA
Middle Name:CLARK
Last Name:LANDRUM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7451 GREENVILLE CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7140
Mailing Address - Country:US
Mailing Address - Phone:813-671-1022
Mailing Address - Fax:561-432-1075
Practice Address - Street 1:6169 S JOG RD
Practice Address - Street 2:SUITE A11
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-6579
Practice Address - Country:US
Practice Address - Phone:561-432-0111
Practice Address - Fax:561-432-1075
Is Sole Proprietor?:No
Enumeration Date:2011-02-24
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1198690225100000X
FLPT27708225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist