Provider Demographics
NPI:1003470154
Name:PETRICH, BRIAN JAMES (LMT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:PETRICH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15769 SUNNY COVE DR SE
Mailing Address - Street 2:
Mailing Address - City:OLALLA
Mailing Address - State:WA
Mailing Address - Zip Code:98359-9594
Mailing Address - Country:US
Mailing Address - Phone:253-861-5297
Mailing Address - Fax:
Practice Address - Street 1:1963 BETHEL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3108
Practice Address - Country:US
Practice Address - Phone:253-861-5297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60936482225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist