Provider Demographics
NPI:1003083411
Name:BROCKWELL, PATRICIA GRACE (LMP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:GRACE
Last Name:BROCKWELL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18118 96TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-6326
Mailing Address - Country:US
Mailing Address - Phone:206-753-8270
Mailing Address - Fax:
Practice Address - Street 1:32015 1ST AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5701
Practice Address - Country:US
Practice Address - Phone:253-927-9382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023917225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist