Provider Demographics
NPI:1417703166
Name:BRANT, RUSSELL TYLER
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:TYLER
Last Name:BRANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 CEDAR LAKE RD STE S
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-2107
Mailing Address - Country:US
Mailing Address - Phone:228-641-2880
Mailing Address - Fax:
Practice Address - Street 1:920 CEDAR LAKE RD STE S
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2107
Practice Address - Country:US
Practice Address - Phone:228-641-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT6476225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist