Provider Demographics
NPI:1912942376
Name:BRANSCOM, DOLORES E (PTA)
Entity type:Individual
Prefix:
First Name:DOLORES
Middle Name:E
Last Name:BRANSCOM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:DELORES
Other - Middle Name:E
Other - Last Name:SIEGRIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:101 W 92 HWY
Mailing Address - Street 2:SUITE H
Mailing Address - City:KEARNEY
Mailing Address - State:MO
Mailing Address - Zip Code:64060-7590
Mailing Address - Country:US
Mailing Address - Phone:816-903-0775
Mailing Address - Fax:816-903-0776
Practice Address - Street 1:101 W 92 HWY
Practice Address - Street 2:SUITE H
Practice Address - City:KEARNEY
Practice Address - State:MO
Practice Address - Zip Code:64060-7590
Practice Address - Country:US
Practice Address - Phone:816-903-0775
Practice Address - Fax:816-903-0776
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006024381225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant