Provider Demographics
NPI:1033582192
Name:HALTOM, BRENDA LYNNE (HEARING INSTUMENT SP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:LYNNE
Last Name:HALTOM
Suffix:
Gender:F
Credentials:HEARING INSTUMENT SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6419
Mailing Address - Country:US
Mailing Address - Phone:360-452-2228
Mailing Address - Fax:360-457-9666
Practice Address - Street 1:830 E 8TH ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6419
Practice Address - Country:US
Practice Address - Phone:360-452-2228
Practice Address - Fax:360-457-9666
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2055237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9054685Medicaid
WA0117480OtherWA. STATE LABOR AND INDUSTRIES