Provider Demographics
NPI:1073733846
Name:HALVERSON, BRENT A (LMP)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:A
Last Name:HALVERSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W. HOLLY ST.
Mailing Address - Street 2:STE. C
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225
Mailing Address - Country:US
Mailing Address - Phone:360-671-1809
Mailing Address - Fax:360-738-3014
Practice Address - Street 1:1300 W. HOLLY ST.
Practice Address - Street 2:STE. C
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225
Practice Address - Country:US
Practice Address - Phone:360-671-1809
Practice Address - Fax:360-738-3014
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009425225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist