Provider Demographics
NPI:1285198010
Name:RICHARD, BRANDI JEAN (LAT, ATC)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:JEAN
Last Name:RICHARD
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:JEAN
Other - Last Name:RIESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:27 FIELDPOINT RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-2607
Mailing Address - Country:US
Mailing Address - Phone:630-551-6704
Mailing Address - Fax:
Practice Address - Street 1:790 REMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-4909
Practice Address - Country:US
Practice Address - Phone:630-551-6704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2024-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960053522255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer