Basic Information
| Provider Information | |||||||||
| NPI: | 1104236082 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | BRENDAN | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 982 PRATT ST | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191241749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159134088 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7 CARNEGIE PLZ | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080031000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774073422 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2014 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.