Brandon Wayne Divan, DPT, PT

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

2022039968 Issued in MO

Practice address

17134 Bel Ray PL
Belton, MO 64012-5331

Phone

(816) 318-0434

Fax

(816) 318-0437

NPI assigned

Aug 22, 2019

Last updated

Oct 6, 2022By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1566432000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1665014400000",
    "number": "1790332807",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "535 E NORTH ST STE C",
            "city": "BRADLEY",
            "state": "IL",
            "postal_code": "609151188",
            "telephone_number": "815-802-7503"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "17134 BEL RAY PL",
            "city": "BELTON",
            "state": "MO",
            "postal_code": "640125331",
            "telephone_number": "816-318-0434",
            "fax_number": "816-318-0437"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "517 E North St",
            "address_purpose": "LOCATION",
            "city": "Bradley",
            "state": "IL",
            "postal_code": "609151258",
            "country_code": "US",
            "telephone_number": "815-802-7503",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "341 S Main St",
            "address_purpose": "LOCATION",
            "city": "Clifton",
            "state": "IL",
            "postal_code": "609277091",
            "country_code": "US",
            "telephone_number": "815-918-5084",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DIVAN",
        "first_name": "BRANDON",
        "middle_name": "WAYNE",
        "credential": "DPT, PT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-08-22",
        "last_updated": "2022-10-06",
        "certification_date": "2022-10-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "IL",
            "license": "070.024617",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "MO",
            "license": "2022039968",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physical Therapist in Belton, MO
• Providers in Belton, MO by specialty
• Physical Therapist in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 6, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.