Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XP0019X | Occupational Therapist - Physical Rehabilitation |
NPI | 1356001820 |
---|---|
Provider Name | Brandon Rome |
First Address | Edwardsville, IL 62025-2328 |
Second Address | Edwardsville, IL 62025-2328 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/12/2021 |
Last Update Date | 27/12/2021 |