Provider Demographics
NPI:1093356024
Name:RILEY, BROOKE E (LMT)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:E
Last Name:RILEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:BROOKELLE
Other - Middle Name:
Other - Last Name:RILEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:4504 GOLDCREST DR NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-9019
Mailing Address - Country:US
Mailing Address - Phone:870-761-2255
Mailing Address - Fax:
Practice Address - Street 1:309 4TH AVE E
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-1106
Practice Address - Country:US
Practice Address - Phone:870-761-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61006033225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist