Provider Demographics
NPI:1053899153
Name:BRANDON, NADIYAH L (OT)
Entity type:Individual
Prefix:
First Name:NADIYAH
Middle Name:L
Last Name:BRANDON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2847 OLDKNOW DR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30318
Mailing Address - Country:US
Mailing Address - Phone:314-371-7717
Mailing Address - Fax:
Practice Address - Street 1:1841 ARROW POINT DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138
Practice Address - Country:US
Practice Address - Phone:314-708-9822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2021-05-20
Deactivation Date:2019-10-18
Deactivation Code:
Reactivation Date:2020-05-12
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 246Z00000X, 372500000X, 3747P1801X, 374U00000X, 171M00000X, 172A00000X, 376J00000X, 376K00000X
GA300688782251J00000X
GA3000688782253Z00000X, 171M00000X
MO105389953171M00000X
MO3000688782251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No172V00000XOther Service ProvidersCommunity Health Worker
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
No372500000XNursing Service Related ProvidersChore Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No374U00000XNursing Service Related ProvidersHome Health Aide
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA150249OtherSUPPLIER
GANBRANDON35OtherID
MO14645636OtherCAQH
MODM3700Medicaid
MOPMOD10414OtherPUBLIC PARTNERSHIP