Provider Demographics
NPI:1588152391
Name:BISHOP, BRANDON JAMES (OTRL)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAMES
Last Name:BISHOP
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 FERGUS RD
Mailing Address - Street 2:
Mailing Address - City:BURT
Mailing Address - State:MI
Mailing Address - Zip Code:48417-9615
Mailing Address - Country:US
Mailing Address - Phone:989-860-0366
Mailing Address - Fax:
Practice Address - Street 1:275 N CALEDONIA DR
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-8844
Practice Address - Country:US
Practice Address - Phone:989-743-3496
Practice Address - Fax:989-743-8681
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201010140225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5201010140Medicaid