Provider Demographics
NPI:1912652975
Name:NOVAK, BRANDON (OTR/L)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:NOVAK
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:IMLAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48444-1037
Mailing Address - Country:US
Mailing Address - Phone:989-494-8611
Mailing Address - Fax:
Practice Address - Street 1:2720 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-2653
Practice Address - Country:US
Practice Address - Phone:810-984-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201012852225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist