Provider Demographics
NPI:1093405185
Name:MEDBURY, BRENDAN RAYVONNE
Entity Type:Individual
Prefix:
First Name:BRENDAN
Middle Name:RAYVONNE
Last Name:MEDBURY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 AIRPORT WAY S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98134-1618
Mailing Address - Country:US
Mailing Address - Phone:206-223-3644
Mailing Address - Fax:
Practice Address - Street 1:1700 AIRPORT WAY S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134-1618
Practice Address - Country:US
Practice Address - Phone:206-223-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWDL548B0D13B101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor