Provider Demographics
NPI:1447579305
Name:PRIVETT, BRENT (PT)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:PRIVETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:603 7TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-3958
Mailing Address - Country:US
Mailing Address - Phone:301-490-0080
Mailing Address - Fax:
Practice Address - Street 1:937 FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93246-4700
Practice Address - Country:US
Practice Address - Phone:559-998-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT36539225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist